, the disease progresses and causes compression and obstruction of the ureter as a result of infiltrative endometriosis , fibrosis , or both . progression may occur without symptoms , causing compromised renal function in as many as 25% to 43% of those with infiltrative ureteral disease . general principles of treatment include resection of the diseased ureter and subsequent ureteroureterostomy or ureteroneocystostomy , depending on the location and length of the remaining ureter . to permit a tension - free anastomosis during a ureteroneocystostomy , sufficient length and mobility of the ureter may be obtained by performing a vesicopsoas hitch procedure or using a boari flap . several studies have shown that laparoscopic techniques may be used successfully to treat endometriosis affecting regions , such as the bowel and genitourinary tract , and to repair ureteral injury . in 1994 we implemented proven techniques of vesicopsoas hitch by laparotomy and modified them for the laparoscopic approach , as previously reported in our first case . the current series reports laparoscopic ureteroneocystostomy and vesicopsoas hitch in 6 women with distal ureteral disease . six women were surgically treated for severe infiltrative endometriosis of the distal ureter with laparoscopic resection of the involved segment of the ureter , ureteroneocystostomy , and vesicopsoas hitch . the mean age at the time of surgery was 39 ( range , 28 to 50 ) , gravidity 1.66 ( range , 0 to 4 ) , and parity 1.66 ( range , 0 to 3 ) . five patients had extensive endometriosis , which had been previously diagnosed in their prior surgeries , and the other was referred for an incidental finding of hydronephrosis detected by a pelvic computer tomography during an evaluation for uterine leiomyomata ( table 1 ) . at the time of this patient 's vesicopsoas hitch procedure , she was diagnosed with severe endometriosis of the bladder , rectum , and ureter . five patients had ureteral stents in place prior to the ureteroneocystostomy procedure , and the other had stents placed during the procedure . * ivp intravenous pyelogram ; ct  computed tomography scan ; uv  utererovesical ; mo  months . preoperatively , all patients received a detailed explanation of the operative laparoscopic procedure , including the risks and benefits involved . as this was part of our routine surgical practice , an approval from the institute 's human investigation board was not obtained . access to the abdominal cavity was obtained in the usual fashion with the multipuncture operative laparoscopy technique . ureterolysis , enterolysis , and adhesiolysis were performed to restore pelvic anatomy 
 ( figure 1 ) . after consultation with the urologist in attendance , the ureter was transected at the site distal to the healthy segment of the ureter ( figure 2 ) . to provide a tension - free ureteroneocystostomy for the remaining length of the ureter , retroperitoneal ureteral mobilization was carried out from above the pelvic brim , and a bladder flap was developed with dissection of vesico , cervico - vaginal fascia . the space of retzius was entered between the obliterated umbilical ligaments as described for laparoscopic retropubic urethropexy . dissection and mobilization proceeded inferiorly to enable the bladder to easily reach the psoas muscle of the affected ureter 's side . the peritoneum lateral to the external iliac vessels was incised , and the psoas muscle was exposed . next , a fishmouth incision was made in the transected ureter with the use of laparoscopic scissors . a 6 f open - ended ureteral catheter was guided cystoscopically into the transected ureter ( figure 2 ) . to decrease the chances of recurrence , the ureter was pulled close to the posterior bladder wall but away from the site of dissection and any potentially residual disease at the ureter bed . with cystoscopic guidance , a neocystostomy site was located and a 1-cm opening was made laparoscopically . in all cases , 4 - 0 polydioxanone sutures were placed incorporating all layers of tissue to anastomose the ureter to the cystostomy site at the 3 , 6 , 9 , and 12 oclock positions over the ureteral catheter ( figure 3 ) . the catheter was then changed to a double - j ureteral stent - over guidewire at the conclusion of the procedure . the mobilized bladder was secured to the ipsilateral psoas muscle tendon ( figure 4 ) with 1 or 2 polyglycon vicryl sutures ( ethicon , sommerville , nj ) , carefully avoiding the genitofemoral nerve . in 3 patients , a jackson - pratt ( allegiance healthcare corporation , mcgraw , illinois ) drain was placed in the pelvis and secured to 1 of the 5-mm cannula sites ( figure 4 ) . one patient experienced mild discomfort due to the ureteral stent , which resolved after its removal . another suffered from mild right leg pain and right lower quadrant discomfort at the site of her jackson pratt drain , which also resolved after its removal . all patients had a normal cystogram performed 2 weeks after surgery prior to foley catheter removal . stents were kept in place for 6 to 8 weeks , and an intravenous pyelogram ( ivp ) was done 2 weeks after removal . all patients had a normal renal ultrasound , ct , or ivp at least 1 year postoperatively . at last follow - up ( mean , 33 months ; range , 28 to 40 months ) , all patients were doing well ( table 1 ) . as endometriosis advances , the ureter is vulnerable to involvement ; therefore , ureters should be evaluated in all patients with pelvic endometriosis . an ivp , renal ultrasound , and/or cystoscopy may be performed for evaluation of the genitourinary tract . it gives the surgeon a magnified view of the operative field for better microsurgical capabilities . superficial endometrial implants of the ureter may be treated by safely excising the lesion using carbon dioxide laser and hydrodissection . if the implants are deeply embedded in tissue , they can cause extensive fibrosis and subsequent ureteral obstruction . small ureteral wall lesions can be vaporized , but this may cause pinhole openings . in these cases , larger ureterostomies can be sutured with subsequent stent placement or at times ureteral resection can be managed by ureteroureterostomy or ureteroneocystostomy . in cases of severe involvement of the distal ureter , transection and diversion several techniques may be implemented to repair ureteral damage , such as ureteroureterostomy , ureteroneocystostomy with or without psoas hitch , boari 's bladder flap , renal transplantation , or ileal interposition . the method of choice depends on several factors , including cause and length of ureteral loss , extent and location of ureteral damage , patient 's condition , bladder capacity , and surgeon 's experience . recently , several studies have shown that in experienced hands , surgeons may repair damaged ureters laparoscopically with equal success and a minimal complication rate . the ureteroneocystostomy with vesicopsoas hitch procedure was first popularized in 1968 by harrow who believed it was a necessary adjunct to ureteral repair due to gynecologic injuries . the laparotomy method has been proven in recent studies to provide positive long - term results . it is reported in urologic studies as a versatile , safe , and ideal method for treatment of lower ureteral disease with minimal complications and a high success rate . reported side effects involve placement of psoas muscle sutures with injury to femoral nerve branches , namely the genitofemoral nerve . because all of these injuries were reported with laparotomies , the authors stated the possibility of the injuries being due to the placement of sidewall retractors . a laparoscopic approach would eliminate this theoretical risk especially since visualization is much better with videolaparoscopy . following the principles of ureteroneocystostomy with vesicopsoas hitch by laparotomy , it is possible to perform this procedure by laparoscopy with a similar outcome to laparotomy and with the known benefits of laparoscopy . operative laparoscopy , although technical and skill dependent , is associated with better visualization and magnification and is less invasive . in experienced hands
objective : to report a series of laparoscopic vesicopsoas hitch procedures performed for the treatment of infiltrative ureteral endometriosis.methods:a retrospective chart review of 6 women with severe endometriosis and ureteral obstruction caused by infiltrative disease of the distal ureter was performed . 
 the patients underwent successful laparoscopic ureteroneocystostomy and vesicopsoas hitch.results:five of the 6 patients had a history of endometriosis , and their obstructions were diagnosed during prior surgeries . 
 the other patient was diagnosed with severe endometriosis of the rectum , bladder , and ureter at the time of the procedure . 
 she was referred for evaluation of an incidental finding of hydroureter and hydronephrosis . 
 three patients were treated with gonadotrophin - releasing hormone ( gnrh ) analog for at least 3 months preoperatively . 
 five patients had ureteral stents in place prior to the psoas hitch surgery . 
 no intraor postoperative complications occurred . 
 all patients had a normal cystogram performed 10 to 14 days postoperatively prior to foley catheter removal . 
 stents were kept in place for 6 to 8 weeks , and an intravenous pyelogram ( ivp ) was done 2 weeks after removal . 
 all patients had a normal renal ultrasound , computer tomography , or intravenous pyelogram at least 1 year postoperatively.conclusion:laparoscopic vesicopsoas hitch can be a safe and effective alternative to the laparotomy with the known benefits of laparoscopy .