Thousands of Indian women experience severe period pain they dismiss as normal. When endometriosis grows on the ureters – the tubes connecting kidneys to bladder – it silently damages kidney function. Surgery offers the only effective treatment to prevent permanent kidney loss.

What Is Ureteric Endometriosis?

Ureteric endometriosis occurs when endometrial tissue grows on or around the ureters. This deep infiltrating endometriosis (DIE) form represents one of the most serious complications because it threatens kidney function.

How Common Is It?

Urinary tract endometriosis affects 1-5.5% of women with endometriosis. Ureteric involvement occurs in 9-23% of these urinary tract cases. Up to 50% of women have no symptoms, making early surgical intervention critical.

Why Ureters Matter for Kidney Health

Ureters are narrow tubes transporting urine from kidneys to bladder. Endometrial tissue causes progressive obstruction leading to:

• Ureteral blockage preventing urine drainage
• Hydronephrosis (kidney swelling from backed-up urine)
• Progressive kidney damage
• Permanent renal failure in untreated cases

Kidney damage becomes irreversible once severe scarring develops.

Symptoms: Recognizing the Silent Threat

Key Warning Signs

Pain timing: Cyclic back/flank pain worsening during periods distinguishes ureteric endometriosis from kidney stones or UTIs.

Pain location: One-sided pain suggests single ureter involvement.

Blood in urine: Appears only during menstruation.

No fever: Unlike infections, fever stays absent unless obstruction causes kidney infection.

Bladder symptoms: Frequency and incomplete emptying occur from downstream pressure.

Critical fact: 50% of women experience no symptoms. Any woman with known endometriosis needs ureter evaluation.

Why Diagnosis Gets Missed

General gynecologists see ureteric endometriosis rarely. They misdiagnose cyclic flank pain as:

• Recurrent urinary infections
• Kidney stones
• Musculoskeletal pain

Red flag for doctors: Reproductive-age woman with menstrual-cycle-correlated flank pain requires imaging even with normal urine cultures.

Surgical Diagnosis and Treatment

Essential Imaging Before Surgery

CT Urography (Most Common Investigation):

• Widely used first-line imaging modality
• Detects ureteral narrowing, obstruction, and hydronephrosis
• Helps assess anatomical distortion before surgical planning

MRI pelvis with IV contrast (gold standard):

• Scheduled days 21-28 of menstrual cycle
• Detects 85-95% of deep endometriosis cases
• Reveals ureter involvement and hydronephrosis severity

Kidney function tests:

Renal DTPA Scan:

• Assesses split kidney function and drainage pattern
• Identifies functional compromise in obstructed kidney
• Critical for deciding urgency and type of surgical intervention

• Serum creatinine and eGFR establish baseline damage
• eGFR below 60 indicates surgical urgency

Cystoscopy: Confirms ureteral opening narrowing.

When Surgery Becomes Mandatory

Operate immediately when imaging shows:

• Any degree of hydronephrosis
• Declining kidney function (rising creatinine)
• Ureteral narrowing greater than 50%

Delay risks permanent kidney loss.

Surgical Techniques

Ureterolysis (Most Common – 60-70% of Cases)

Surgeon carefully dissects endometrial tissue from ureter surface while preserving ureter integrity. Success rate reaches 85-90% for external compression cases.

Segmental Ureteral Resection (25-30% of Cases)

Removes damaged ureter segment and reconnects healthy ends (ureteroureterostomy). Requires ureteral stent for 4-6 weeks post-surgery.

Ureteral Reimplantation (5-10% of Cases)

For extensive lower ureter damage, surgeon reattaches ureter directly to bladder.

Nephrectomy (Last Resort)

Removes non-functioning kidney. Affects 9-11.5% of late-diagnosed cases. Early surgery prevents this outcome.

Why Multidisciplinary Surgery Succeeds

Requires surgical team expertise:

• Advanced laparoscopic gynecologic surgeon (lead)
• Urologist trained in ureter reconstruction
• Intraoperative imaging capability

Ask surgeons: “How many ureteric endometriosis cases do you operate yearly? What is your nephrectomy rate?” Centers with <5% nephrectomy rates demonstrate expertise.

Post-surgery monitoring:

• Kidney ultrasound every 6 months first 2 years
• Annual kidney function tests
• MRI if flank pain returns

Emergency Warning Signs

Seek immediate surgical evaluation for:

• Sudden severe flank pain (10/10 intensity)
• Inability to urinate 6+ hours
• High fever with back pain
• Visible blood clots in urine

These indicate acute obstruction requiring emergency ureteral stenting or surgery.

Finding Surgical Expertise

1. “How many ureteric endometriosis surgeries have you performed?”
2. “What is your personal nephrectomy rate?”
3. “Do you collaborate with urology during ureteric cases?”

Take Action Now

Your kidneys cannot regenerate. Untreated ureteric endometriosis causes permanent function loss. Surgery remains the only proven treatment.

Immediate steps:

1. Request pelvic MRI with ureter protocol from your gynecologist
2. Get kidney function tests (creatinine, eGFR)
3. Find advanced laparoscopy surgeon with ureteric experience
4. Document cyclic flank pain pattern

Surgical reality: Once hydronephrosis appears on imaging, delay risks kidney loss. Act decisively.

Medical Disclaimer: This content provides surgical education only. Consult qualified laparoscopic surgeons for diagnosis and treatment planning.