Current research status and development trends of urinary tract endometriosis: a bibliometric analysis

Introduction

Endometriosis is a chronic inflammatory disease characterized primarily by pain and infertility, affecting nearly 10% of women of reproductive age worldwide. Additional symptoms often include non-cyclical pelvic pain, abdominal bloating, altered bowel habits, and urinary symptoms (1,2). Endometriosis can occur in various parts of the body; however, it predominantly arises in the pelvic region, particularly in the ovaries, pelvic peritoneum, uterosacral ligaments, and rectovaginal septum (3).

Urinary tract endometriosis (UTE), while relatively uncommon, comprises only 1% to 2% of endometriosis cases and poses risks for urinary obstruction and renal dysfunction. UTE encompasses endometriosis affecting the bladder, ureters, kidneys, and urethra (2). The most commonly affected sites are the bladder (70–85%) and ureters (9–23%), with the kidneys (4%) and urethra (2%) being less frequently involved (4). Symptoms of bladder endometriosis (BE) typically include dysuria, increased urinary frequency, recurrent urinary tract infections, hematuria, and even urinary incontinence. In contrast, ureteral endometriosis (UE) often presents without specific symptoms but can lead to covert obstructive uropathy and renal failure (5).

Historically, UTE was regarded as a gynecological condition managed by obstetricians and gynecologists. However, the nature of symptoms often leads patients to first consult urologists. Consequently, a comprehensive understanding and accurate diagnosis of this condition are critical. As treatment experiences have accumulated, it has become increasingly recognized that endometriosis is a multi-organ and systemic inflammatory disease requiring long-term individualized management, adjusted according to symptom severity, fertility goals, and lifestyle choices. Thus, establishing a multidisciplinary team, including specialists trained in endometriosis and high-level surgeons experienced in managing deep infiltrating endometriosis, is recommended (6).

Given the rising incidence of endometriosis and its occurrence in younger populations (7,8), the number of UTE patients is increasing annually, with prevalence rates among deep infiltrating endometriosis patients reaching as high as 20.7% to 52.6% (9,10). Therefore, the clinical significance of UTE is becoming more pronounced. Currently, the primary challenges in diagnosis and treatment revolve around three key issues: first, how to achieve early diagnosis and timely intervention for UTE; second, how to select safe and effective treatment options that minimize complications; and third, how to reduce the likelihood of postoperative recurrence.

Recent years have seen growing international interest in research related to UTE. A comprehensive analysis of such studies can illuminate current research trends and future directions. Bibliometric analysis, employing mathematical and statistical techniques to qualitatively and quantitatively assess the distribution, structure, and developmental trajectory of published articles, serves to clarify emerging trends and information structures in relevant research fields (11). This study utilizes the Web of Science Core Collection (WoSCC) database to retrieve bibliometric data related to UTE and employs bibliometric software tools such as CiteSpace and VOSviewer for the analysis and visualization of the influence of different authors, countries, institutions, and journals, thereby revealing dynamic research trends and highlighting current and future focal areas. To our knowledge, this study represents the first bibliometric analysis of UTE, significantly enhancing awareness of this obscure disease and providing new insights for future clinical and mechanistic research directions.

Methods

Database source and search strategy

We conducted a comprehensive literature search in the Science Citation Index Expanded and Social Sciences Citation Index databases within the Web of Science Core Collection (WoSCC) for publications dated from January 1, 1995, to June 30, 2024. WoS is a highly regarded academic database that provides comprehensive coverage of various scholarly journals and widely utilized by researchers worldwide (12,13). Additionally, it offers data on co-cited references and co-cited journals, making it more comprehensive for bibliometric research compared to other databases such as PubMed and Scopus (14).

The detailed search strategy utilized in WoSCC is provided in the Supplementary file (Appendix 1). To minimize analytical bias due to database updates, we downloaded the entire WoSCC record, including cited references, in text format within a single day for subsequent analysis. The publication types were limited to articles and reviews, and the language was restricted to English. The specific data collection and analysis process is illustrated in Figure 1.

Figure 1 Flowchart of this research.

Data analysis and visualization

VOSviewer is a software tool designed for constructing and visualizing bibliometric networks. It can create and visualize co-occurrence networks of important terms extracted from literature through text mining (15). In this study, VOSviewer was utilized to analyze and visualize the collaboration networks among countries/regions and journals within the field. Additionally, keyword and citation analysis were performed using this software. CiteSpace is a widely used classic software for bibliometric analysis that operates in a Java environment, allowing for data analysis and visualization of bibliometric information (16). In this research, CiteSpace was utilized for analyzing and visualizing the collaboration network among institutions and authors, conducting burst detection analysis of keywords, and performing overlay visualization of journals. Bibliometrix is a popular R package that integrates various bibliometric analysis functions and facilitates convenient web operations through Shinyapp (Biblioshiny) (17). This study used Biblioshiny to visualize international collaborations among countries, rank the influence of source journals, and analyze the core areas, as well as the current status of research themes. Lastly, Microsoft Office software was used to create line graphs depicting the annual publication counts. These tools collectively enabled a comprehensive bibliometric analysis, facilitating insights into the trends and dynamics of research within the domain of UTE.

Results

Overview of annual publications

A systematic search was conducted in the Web of Science Core Collection database, resulting in 508 publications. After limiting the language to English, 469 documents were obtained. Articles classified as either “Article” or “Review” were included for further analysis, yielding a total of 361 articles, comprising 310 original research articles and 51 review articles. Of these, 172 articles (approximately 47.65%) were published between 2015 and 2024, while 138 articles (approximately 38.23%) were published from 2005 to 2014, and 51 articles (approximately 14.13%) were published from 1995 to 2004. Overall, the number of studies on UTE has shown an upward trend over the past 30 years (Figure 2).

Figure 2 The number of publications each year in this field and the overall trend.

National/regional collaboration

The search results indicate that research in this field has been conducted by 610 institutions across 48 countries over the past 30 years. The top ten countries with the highest publication counts are listed in Table 1. Italy leads with 86 publications, followed by France with 61, and the United States with 48. Among the top ten countries, six are from Europe, while two each are from Asia and the Americas.

Further analysis and visualization of inter-country collaborations using VOSviewer reveal strong collaborative networks exist among several European countries, including France, Italy, the UK, Switzerland, Belgium, and Germany (Figure 3A). Temporal mapping indicates that the United States and Belgium were among the earliest countries to conduct relevant research in this field (Figure 3B). In recent years, Asian countries such as China and Japan have also initiated research in this area; however, international collaboration remains insufficient (Figure 3C,3D). Among the 610 institutions, 20 have published five or more papers, 32 institutions have published three to four papers, and 558 institutions have published only one paper. The three institutions with the highest number of publications are the University of Paris, University of Milan, and University of Bologna, collectively contributing 52 articles, which account for 14.4% of the total. The results regarding institutional collaborations show that cooperation is primarily concentrated in specific regions of Europe and the United States, however, intercontinental collaborations remain limited (Figure 3E). This lack of intercontinental cooperation further widens the gap in healthcare resources between developed and underdeveloped regions, thereby impeding the global advancement of medical science in this field.

Figure 3 Display of cooperation relations between countries and institutions. (A) Network diagram of cooperation between countries in this field. (B) Time mapping network diagram of cooperation between countries. (C) Annual growth trends in the number of publications in the six countries with the most publications in this field. (D) Bar chart of the annual number of publications and international cooperation for the top 20 countries producing the most publications in this field. SCP: number of publications with authors in the same country; MCP: number of publications with authors in multiple countries. (E) Cooperation network between research institutions in this field. A node with variable colors means papers are produced in this institution in different years.

Author collaboration

A total of 1,699 authors have contributed to research in this area. Among them, 31 authors have published five or more related studies, 219 authors have published two to four studies, and 1,449 authors have published only one study. The authors with the highest publication counts are summarized in Table 2. Charles Chapron from France is the most prolific author in this domain, with 31 publications, while Pietro Santulli and Bruno Borghese from France, along with Renato Seracchioli from Italy, have each published more than ten articles. Notably, there is a close collaborative relationship among these French scholars (Figure 4).

Figure 4 Cooperation relations between authors in this field. The size of each node corresponds to the number of papers published by that author. The lines connecting the nodes represent the cooperative relationship between authors. Different colors represent different years in which the author produced the paper.

Journals and co-cited journals

The retrieved publications were disseminated across 122 different journals, and we constructed a visual network of these journals (Figure 5A). Among these, 21 journals published five or more studies, 16 journals published three to four studies, and 85 journals published one to two studies. The top ten journals with the highest number of publications are listed in Table 3. According to Bradford’s Law, journals publishing specialized papers in a given field can be categorized into core, related, and non-related areas. The shaded region in Figure 5B illustrates the core journals associated with UTE research. The journal with the highest publication count is the Journal of Minimally Invasive Gynecology, with a total of 39 articles. Following this, Fertility and Sterility published 26 articles, while Human Reproduction, European Journal of Obstetrics & Gynecology and Reproductive Biology, and Urology each published over ten articles. The most cited journals are Fertility and Sterility (n=1,883), Human Reproduction (n=1,659), and Journal of Minimally Invasive Gynecology (n=944).

Figure 5 Overview of journals in this field. (A) Visualization of journals based on Bradford’s Law. (B) Visualization of journal co-citation analysis network on time mapping.

To further analyze the distribution of published and cited journals, we employed CiteSpace for dual-map overlay analysis and visualization (Figure 6). The left map represents citing journals, while the right map indicates cited journals. The labels represent the themes covered by the journals. The colored curves illustrate the reference pathways from the citing map on the left to the cited map on the right. This dual-map overlay reveals major citation pathways, illustrating that articles in Medicine and Clinical fields are primarily cited by researchers in Health and Nursing disciplines.

Figure 6 The dual-map overlay of journals related to this field.

Keyword analysis

A total of 966 keywords were extracted, and we selected the top 100 most frequently occurring keywords to create a co-occurrence network diagram (Figure 7A). The color tones of the points on the map in Figure 7B depict the temporal dimension of research hotspots related to the keywords. Table 4 presents the 20 most frequently occurring keywords. We also utilized CiteSpace to analyze keyword bursts to monitor dynamic changes in research focus. As shown in Figure 7C, early burst keywords included vesical endometriosis, rectovaginal septum, laparoscopic treatment, ovarian endometriosis, obstruction, urinary tract, and partial cystectomy. Recently, keywords such as proposal, prevalence, deep infiltrating endometriosis, term follow-up, surgery, and pathogenesis have emerged as central research focuses.

Figure 7 Keyword correlation analysis. (A) Co-citation analysis of keywords in this field. (B) Keyword network based on time mapping. (C) Analysis of explosive words. (D) Thematic map of keywords.

Figure 7D displays the thematic map generated by the Bibliometrix package, comprising mainstream themes, including isolated topics (niche themes), new topics (emerging themes), hot topics (motor themes), and essential topics (basic themes). Each bubble represents a network cluster, with the name determined by the most frequently appearing keywords. The size of the bubble correlates with the frequency of the clustered keywords, while the position of the bubble is determined by cluster centrality and density. In this study, the Walktrap algorithm was employed for data clustering. Topics such as management and assisted reproduction technology are classified as essential topics significant to the research field of UTE, which remains underexplored. BE and UE are identified as hot topics, whereas renal endometriosis and cancer-associated UTE are classified as new topics.

Co-citation analysis

Co-cited references refer to the analysis of 5,120 studies that share common citations. Eight references were co-cited more than 50 times. The most co-cited reference is Camran Nezhat’s 1996 publication in Fertility and Sterility titled “Urinary tract endometriosis treated by laparoscopy”, which has been cited 71 times. Table 5 lists the top ten co-cited references, while Table 6 presents the ten most cited authors. Charles Chapron has the highest citation count at 415, with seven additional authors exceeding 100 citations. Figure 8 provides a visualization of the co-citation relationships among authors as well as the co-citation relationships among references, highlighting prominent authors and important references.

Figure 8 Co-citation network of authors and references in this field. (A) Network visualization of co-cited authors in the field. The figure included labels for the top 20 authors with the highest number of co-citations. (B) The Network map of co-cited references from the publications. The co-citation relationship of reference with the highest number of co-citations was highlighted.

Discussion

General information

We conducted a bibliometric analysis of 361 publications related to UTE over the past three decades. Throughout this period, the overall scientific output has shown a steady increase, highlighting steady progress and growing interest in the field. Notably, the ten most frequently cited articles were predominantly published between 2000 and 2006, suggesting that earlier studies tend to be cited more frequently compared to more recent research due to temporal factors.

Analysis of countries and regions indicates that Europe is the primary center for scientific output in this field. Italy and France stand out, each having published over 50 papers. According to institutional analysis, the top three institutions by article count are led by the University of Paris, followed by the University of Milan and the University of Bologna from Italy, aligning with the findings from the country-level analysis. It is noteworthy that Asia, with its large population base, has the potential to contribute significantly to UTE research despite its low incidence rates. However, contributions from Asian countries in this research area remain limited, presenting opportunities for further exploration. In recent years, China and Japan, as representative Asian countries, have seen a gradual increase in related research, yet there is a noticeable lack of international communication and collaboration. Our research helps researchers identify countries and institutions that are at the forefront of this field internationally, providing suitable targets for collaborative learning. Intercontinental and national collaborations can enhance research quality, expand sample sizes, provide multiple perspectives for observation, and promote the exchange and development of technologies. These collaborative forms contribute to accelerating scientific progress, improving the level of medicine, and ultimately benefiting patients globally.

Journal analysis indicates that the Journal of Minimally Invasive Gynecology and Fertility and Sterility are the two leading journals in terms of both publication volume and citation counts, reflecting their status as the most widely read and popular journals in the UTE field. Among them, Fertility and Sterility ranks highest in impact factor, indicating it has the greatest average number of citations per article in UTE research. Furthermore, based on Bradford’s Law, seven journals have been identified as major contributors to significant publications in this field, underscoring their substantial influence and authority within the research community. Analyzing journals in this manner provides valuable guidance for researchers in selecting the most appropriate venues for their publications. By understanding popularity, impact factors, and rankings of core journals, researchers can ensure their findings reach the appropriate audience, thereby potentially making a significant impact in the study of UTE.

Research hotspots and key focus areas of UTE

This article summarizes the research hotspots and developmental directions in the field of UTE using methods such as keyword frequency analysis, timeline mapping, burst detection, and thematic clustering maps. BE and UE account for approximately 90% of UTE cases, making them significant topics of interest (18). Historically, research on UTE has primarily focused on surgical treatments; however, there is now a shift towards comprehensive management, which includes early diagnosis, treatment selection, preoperative assessment and preparation, and long-term postoperative follow-up.

Definition and classification

Understanding the definition and clinical and pathological classification of UTE is beneficial for diagnosis and treatment by clinicians. UE can be defined as any condition in which endometriosis or its related fibrosis causes compression or torsion of the normal ureteral anatomy, even in the absence of hydronephrosis (19). Based on the depth of infiltration of uterine endometriosis into the ureteral wall, it can be classified into two types: extrinsic UE, which is the most common type (80%) and involves the outer layer; and intrinsic UE, which affects the tissues from the muscular layer to the mucosal layer. According to the severity of ureteral involvement, two clinical classifications arise: severe UE, where either extrinsic or intrinsic pathology leads to urinary flow obstruction; and mild UE, where no ureteral stenosis is present. Additionally, the ureter may also be surrounded by fibrotic narrowing rather than endometrial tissue, thus leading to the classification of endometriotic UE and fibrotic UE based on histological patterns (19,20).

BE is defined as the presence of endometriotic lesions in the bladder wall, including partial or full-thickness infiltration, and/or involvement of the bladder epithelium, with detrusor muscle involvement being the most common. Compared to UE, there has been limited research on the classification of BE. Considering that its pathogenesis is not fully understood, it can be broadly classified into primary and secondary forms (secondary to iatrogenic deposition or bladder injury following pelvic surgeries such as cesarean section or hysterectomy) (21).

Early diagnosis

About 50% of patients with UTE lack obvious urinary symptoms, often leading to delayed diagnosis (22-24). Early diagnosis is crucial for effective treatment. Detailed medical history, physical examination, and auxiliary examinations can provide preliminary assessments of the condition. UTE patients frequently have concurrent endometriosis in other anatomical locations, presenting with clinical manifestations such as dysmenorrhea and dyspareunia. Typical signs during gynecological examinations include nodules in the posterior vaginal fornix, adnexal masses, and a fixed or laterally displaced uterus. When combined with symptoms like cyclic hematuria, dysuria, increased urinary frequency, recurrent urinary tract infections, and suprapubic pain, there should be a high suspicion of UTE, warranting further laboratory investigations. A meta-analysis encompassing 23 studies demonstrated that transvaginal ultrasound and pelvic magnetic resonance imaging (MRI) possess high diagnostic value for UTE; however, there is a lack of clinical evidence supporting the optimal diagnostic strategy (25).

Clinical and pathological factors associated with UTE can increase the vigilance of clinicians in early disease detection. Gabriel et al. found a significant correlation between UTE and age as well as involvement of the uterosacral ligaments (26). Another prospective observational study showed that a transverse diameter of posterior deep infiltrating endometriosis nodules >1.8 cm, parametrial involvement, and a history of previous endometriosis surgery appeared to be risk factors for UE (27). Establishing mathematical models by selecting effective predictive factors can be beneficial in evaluating the likelihood of UTE, facilitating early diagnosis of the disease.

Comprehensive assessment

The infiltrative nature of UTE and its effect on anatomical structures often result in multiple systems being involved in the abdominal cavity. Gynecologists may require additional surgical training to manage urinary and intestinal endometriosis, though this remains a subject of debate (28). Currently, the fundamental solution to this issue involves close collaboration among multidisciplinary teams, including gynecology, urology, gastrointestinal surgery, ultrasound, and radiology specialists. Such teamwork allows for comprehensive evaluations of the condition, enabling the development of optimal treatment plans while reducing complications and ensuring timely intervention when complications arise (29).

Despite the high diagnostic values of ultrasound and pelvic MRI for UTE, there are limitations in identifying BE lesions smaller than 3 cm in diameter (30). To ensure patient benefits, an ideal approach would involve thorough mapping of deep infiltrating endometriosis lesions prior to surgery to evaluate their location and size. When ultrasound and MRI evaluations are insufficient, computed tomography and intravenous urography may serve as supplementary methods for preoperative diagnosis and assessment of both extrinsic and intrinsic ureteral involvement (31,32). In addition, cystoscopy can reveal various findings that not only assist in diagnosing but also help exclude malignant tumors and measure the distance from the lesions to the ureteral orifice, thereby reducing the risk of ureteral injury (33).

If endometriosis is discovered incidentally during surgery, a urologist should perform a biopsy if necessary. When planning to excise bladder lesions, laparoscopic and cystoscopic evaluations should be conducted to trace the entire lesion before starting the resection.

Treatment options

The goal of treating BE is to alleviate symptoms and prevent potential renal damage. Treatment options may include observation, medication, or surgical intervention. Data comparing the effectiveness of surgical versus medical treatments for BE are limited. Experts recommend initiating a trial of combined oral contraceptives, progesterone, or GnRH analogs for 6 months in patients without hydronephrosis-related symptoms, reserving surgical options for those unresponsive to medical therapy or suffering from hydronephrosis (34,35). Women responding to medical treatment can continue until menopause, desire pregnancy, or achieve optimal quality of life with reduced progression risks.

Surgical intervention for UE aims to relieve ureteral obstruction and prevent recurrence. Solely relying on medical treatment may not be effective for UE, as it may not reverse the fibrotic components causing ureteral obstruction, posing serious risks of renal function decline (36). However, in the absence of obstruction, if patients require it, medical management may be considered to lower the risks associated with surgery.

There remains some debate regarding the necessity of preoperative medical treatment. Studies suggest that hormonal therapy for endometriosis does not significantly impact the lesions of BE and UE (37). However, preoperative endocrine treatment can effectively reduce edema in surrounding tissues, facilitating easier and cleaner resection, subsequently improving surgical success rates (38). The efficacy of these treatments in the context of UTE warrants further investigation.

Surgical treatment

The surgical approach for BE includes both the excision of serosal lesions and full-thickness resection of the lesions. Laparoscopic excision increases the likelihood of completely removing nodules; however, it may inadvertently lead to excessive resection of the bladder wall and increase the risk of complications, especially in cases involving large lesions near the ureteral orifice. Therefore, a combination of laparoscopy and cystoscopy is considered the most effective method for achieving complete excision of BE nodules, alleviating symptoms, and reducing intraoperative and postoperative complications as well as recurrence rates (39).

In terms of UE, the surgical method depends on the symptoms, location of the lesions, degree of compression, and renal function. The surgical treatment options for UE include conservative ureterolysis with removal of adjacent lesions or more radical approaches such as ureterectomy with end-to-end anastomosis, ureteral-bladder anastomosis, or nephroureterectomy (40). For women with severe stenosis, preoperative placement of a ureteral pig-tail stent may be necessary to limit ongoing renal function loss. In patients without renal function impairment, ureteral catheters or stents can be placed during surgery (2).

Currently, minimally invasive techniques are regarded as the gold standard for the surgical treatment of deep infiltrating endometriosis. Robot-assisted surgery can further enable 3D visualization, improve spatial anatomical access to the narrow pelvis, and enhance suture capabilities with a shorter learning curve (41). In this context, robot-assisted surgery may provide technology to overcome some of the limitations of laparoscopic surgery while ensuring safety and efficacy (42). Some surgeons utilizing robot-assisted techniques for deep infiltrating endometriosis claim advantages in complex pelvic pathology, obesity, and previous surgical history (43).

In addition to advancements in surgical instruments, there have been continuous innovations in the exploration of intraoperative adjunctive techniques. Near-infrared imaging with indocyanine green (NIR-ICG) involves intravenous injection of indocyanine green followed by intraoperative imaging using near-infrared radiation, which assists in three-dimensional and high-resolution visualization, highlighting the anatomical structures of major vessels and microvasculature, as well as tissue perfusion. On the one hand, it can enhance the intraoperative visualization of vascular lesions, improve lesion detection rates, and potentially reduce recurrence rates and the need for subsequent interventions (44,45). On the other hand, it can assess residual vasculature in the ureter, appearing to be a feasible, safe, and useful tool for evaluating ureteral perfusion and guiding surgical decision-making to prevent surgical complications (46). However, further large-scale controlled studies are still required to validate this method.

Long-term management

Predictors of UTE recurrence include being under 25 years at the time of the first surgery and having comorbid autoimmune diseases, while postoperative adjunctive therapies have shown protective effects (47). Hormonal medications play a critical role in symptom control and significantly improve quality of life and disease recurrence rates in surgically treated patients (48). It is recommended that women who have undergone surgical treatment and do not require fertility preservation receive long-term hormonal therapy, such as GnRH agonists and oral contraceptives, for secondary prevention of endometriosis-related symptom recurrence (49,50). Case reports indicate that using a levonorgestrel-releasing intrauterine system (LNG-IUS) postoperatively in patients with BE and UE-related hydronephrosis has demonstrated good control over disease recurrence (51,52). This treatment approach is well-tolerated by patients due to limited side effects, positively impacting their quality of life. Research on fertility is more extensive among patients with deep infiltrating endometriosis compared to those with UTE, with only a few studies assessing fertility outcomes after UTE surgical treatment. Some research suggests that two-thirds of women wishing to conceive succeeded, mostly through assisted reproductive technologies (53), underscoring the importance of multidisciplinary care.

Following surgical treatment, a follow-up plan should be established involving physical examinations and abdominal ultrasounds for long-term monitoring of symptom recurrence or anatomical relapse. Physical examinations and ultrasounds should be conducted every 6 months during the first year, followed by annual assessments in the subsequent 2 years (24,53).

New topics in UTE research

Cases of renal and UE are extremely rare and easily misdiagnosed, often reported in the literature as case studies that provide valuable clinical insights (54,55). The incidence of malignant transformation of ovarian endometriosis is similar to or lower than that of ovarian endometriosis, with the probability of UTE malignancy estimated at 1.5%, primarily presenting as endometrial-type histology, suggesting a relationship with hormonal influences (56). All women diagnosed with endometriosis should be informed about the increased risk of malignant tumors and the potential benefits of surgical excision.

Conclusions

This study analyzed articles related to UTE published over the past 30 years, systematically exploring trends in publications, journals, countries, institutions, authors, landmark articles, collaboration networks, and keyword analyses. The focus of UTE research has shifted from surgical treatment to comprehensive management, encompassing various aspects such as early diagnosis, treatment options, preoperative assessment and preparation, and long-term postoperative follow-up. Increasing awareness, facilitating early diagnosis, and strengthening interdisciplinary collaboration are crucial for advancing UTE management.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-546/prf

Funding: This study was supported by Beijing Natural Science Foundation (No. 7232063).

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-24-546/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med 2020;382:1244-56. [Crossref] [PubMed]
2. Leonardi M, Espada M, Kho RM, et al. Endometriosis and the Urinary Tract: From Diagnosis to Surgical Treatment. Diagnostics (Basel) 2020;10:771. [Crossref] [PubMed]
3. Nowak I, Bochen P. The Antigen-Processing Pathway via Major Histocompatibility Complex I as a New Perspective in the Diagnosis and Treatment of Endometriosis. Arch Immunol Ther Exp (Warsz) 2024.
4. Berlanda N, Vercellini P, Carmignani L, et al. Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. Obstet Gynecol Surv 2009;64:830-42. [Crossref] [PubMed]
5. Youssef Y, Neblett MF 2nd, Cope AG, et al. Surgical Management of Endometriosis Involving the Bladder and Ureter. Urology 2024;184:e258-9. [Crossref] [PubMed]
6. Johnson NP, Hummelshoj L. Consensus on current management of endometriosis. Hum Reprod 2013;28:1552-68. [Crossref] [PubMed]
7. Symons LK, Miller JE, Kay VR, et al. The Immunopathophysiology of Endometriosis. Trends Mol Med 2018;24:748-62. [Crossref] [PubMed]
8. Chapron C, Marcellin L, Maitrot-Mantelet L, et al. Questionnaire-based screening of adolescents and young adult women can identify markers associated with endometriosis. Hum Reprod 2024;39:1664-72. [Crossref] [PubMed]
9. Knabben L, Imboden S, Fellmann B, et al. Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification. Fertil Steril 2015;103:147-52. [Crossref] [PubMed]
10. Hu Z, Li P, Liu Q, et al. Ureteral endometriosis in patients with deep infiltrating endometriosis: characteristics and management from a single-center retrospective study. Arch Gynecol Obstet 2019;300:967-73. [Crossref] [PubMed]
11. Liu S, Hu X, Zhang J, et al. Bibliometric analysis of T cells in allergic rhinitis. Heliyon 2024;10:e32756. [Crossref] [PubMed]
12. Li MM, Tang XH, Wang LM. Study on the predictive significance of PLR, SII and RPR in ovarian endometriotic cyst. Zhonghua Fu Chan Ke Za Zhi 2023;58:672-9. [PubMed]
13. Wu T, Wu Y, Nie K, et al. Bibliometric analysis and global trends in uterus transplantation. Int J Surg 2024;110:4932-46. [Crossref] [PubMed]
14. Zhang X, Yi K, Xu JG, et al. Application of three-dimensional printing in cardiovascular diseases: a bibliometric analysis. Int J Surg 2024;110:1068-78. [PubMed]
15. van Eck NJ, Waltman L. Software survey: VOSviewer, a computer program for bibliometric mapping. Scientometrics 2010;84:523-38. [Crossref] [PubMed]
16. Synnestvedt MB, Chen C, Holmes JH. CiteSpace II: visualization and knowledge discovery in bibliographic databases. AMIA Annu Symp Proc 2005;2005:724-8. [PubMed]
17. Aria M, Cuccurullo C. Bibliometrix: An R-Tool for Comprehensive Science Mapping Analysis. Journal of Informetrics 2017;11:959-75. [Crossref]
18. Charatsi D, Koukoura O, Ntavela IG, et al. Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis. Adv Med 2018;2018:3461209. [Crossref] [PubMed]
19. Seracchioli R, Raimondo D, Di Donato N, et al. Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series. Hum Reprod 2015;30:833-9. [Crossref] [PubMed]
20. Raimondo D, Mabrouk M, Zannoni L, et al. Severe ureteral endometriosis: frequency and risk factors. J Obstet Gynaecol 2018;38:257-60. [Crossref] [PubMed]
21. Fleischer K, Bachi A, Kam J, et al. Bladder Endometriosis: What do we know and what is left to find out? A narrative review. Best Pract Res Clin Obstet Gynaecol 2024;96:102536. [Crossref] [PubMed]
22. Sillou S, Poirée S, Millischer AE, et al. Urinary endometriosis: MR imaging appearance with surgical and histological correlations. Diagn Interv Imaging 2015;96:373-81. [Crossref] [PubMed]
23. Cavaco-Gomes J, Martinho M, Gilabert-Aguilar J, et al. Laparoscopic management of ureteral endometriosis: A systematic review. Eur J Obstet Gynecol Reprod Biol 2017;210:94-101. [Crossref] [PubMed]
24. Seracchioli R, Mabrouk M, Montanari G, et al. Conservative laparoscopic management of urinary tract endometriosis (UTE): surgical outcome and long-term follow-up. Fertil Steril 2010;94:856-61. [Crossref] [PubMed]
25. Tian Z, Zhang YC, Sun XH, et al. Accuracy of transvaginal ultrasound and magnetic resonance imaging for diagnosis of deep endometriosis in bladder and ureter: a meta-analysis. J Obstet Gynaecol 2022;42:2272-81. [Crossref] [PubMed]
26. Gabriel B, Nassif J, Trompoukis P, et al. Prevalence and management of urinary tract endometriosis: a clinical case series. Urology 2011;78:1269-74. [Crossref] [PubMed]
27. Arena A, Del Forno S, Orsini B, et al. Ureteral endometriosis, the hidden enemy: multivariable fractional polynomial approach for evaluation of preoperative risk factors in the absence of ureteral dilation. Fertil Steril 2021;116:470-7. [Crossref] [PubMed]
28. Pellerin M, Faller E, Minella C, et al. Surgical management of deep pelvic endometriosis in France: Do we need to be a pelvic surgeon to deal with DPE? J Gynecol Obstet Hum Reprod 2021;50:102158. [Crossref] [PubMed]
29. Barbanti C, Labanca L, Gentile F, et al. Urinary Tract Endometriosis: A Multidisciplinary Fight Against a Silent Enemy. J Minim Invasive Gynecol 2022;29:584-5. [Crossref] [PubMed]
30. Kołodziej A, Krajewski W, Dołowy Ł, et al. Urinary Tract Endometriosis. Urol J 2015;12:2213-7. [PubMed]
31. Zannoni L, Del Forno S, Coppola F, et al. Comparison of transvaginal sonography and computed tomography-colonography with contrast media and urographic phase for diagnosing deep infiltrating endometriosis of the posterior compartment of the pelvis: a pilot study. Jpn J Radiol 2017;35:546-54. [Crossref] [PubMed]
32. Coppola F, Paradisi R, Zanardi S, et al. Computed Tomography-Colonography With Intravenous Contrast Medium and Urographic Phase for the Evaluation of Pelvic Deep Infiltrating Endometriosis of Intestinal and Urinary Tract. J Comput Assist Tomogr 2019;43:513-8. [Crossref] [PubMed]
33. Geng JH, Lee YC. Bladder Endometriosis. N Engl J Med 2019;381:e43. [Crossref] [PubMed]
34. Fedele L, Bianchi S, Montefusco S, et al. A gonadotropin-releasing hormone agonist versus a continuous oral contraceptive pill in the treatment of bladder endometriosis. Fertil Steril 2008;90:183-4. [Crossref] [PubMed]
35. Westney OL, Amundsen CL, McGuire EJ. Bladder endometriosis: conservative management. J Urol 2000;163:1814-7. [Crossref] [PubMed]
36. Yohannes P. Ureteral endometriosis. J Urol 2003;170:20-5. [Crossref] [PubMed]
37. Topdağı Yılmaz EP, Yapça ÖE, Aynaoğlu Yıldız G, et al. Management of patients with urinary tract endometriosis by gynecologists. J Turk Ger Gynecol Assoc 2021;22:112-9. [Crossref] [PubMed]
38. Li L, Leng J-h, Lang J-h, et al. Zhonghua Fu Chan Ke Za Zhi 2011;46:266-70. [Diagnosis and Treatment of Ureter Endometriosis]. [PubMed]
39. Shah P, Shah P, Patel PB, et al. Bladder Endometriosis: Management by Cystoscopic and Laparoscopic Approaches. J Minim Invasive Gynecol 2019;26:807-8. [Crossref] [PubMed]
40. Barra F, Scala C, Biscaldi E, et al. Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility. Hum Reprod Update 2018;24:710-30. [Crossref] [PubMed]
41. Tamhane N, Roberts B, Wiegand L, et al. Robotic Surgery for Urologic Deep Infiltrating Endometriosis: A Review and Case Presentations. Surg Technol Int 2020;37:154-60. [PubMed]
42. Di Maida F, Mari A, Morselli S, et al. Robotic treatment for urinary tract endometriosis: preliminary results and surgical details in a high-volume single-Institutional cohort study. Surg Endosc 2020;34:3236-42. [Crossref] [PubMed]
43. Ferrari FA, Youssef Y, Naem A, et al. Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward? Front Med (Lausanne) 2024;11:1387036. [Crossref] [PubMed]
44. Vizzielli G, Cosentino F, Raimondo D, et al. Real three-dimensional approach vs two-dimensional camera with and without real-time near-infrared imaging with indocyanine green for detection of endometriosis: A case-control study. Acta Obstet Gynecol Scand 2020;99:1330-8. [Crossref] [PubMed]
45. Mahgoub S, Saad RM, Vashisht A, et al. "The Green Peace" How ICG can prevent complications in endometriosis surgery? Best Pract Res Clin Obstet Gynaecol 2024;96:102505. [Crossref] [PubMed]
46. Raimondo D, Borghese G, Mabrouk M, et al. Use of Indocyanine Green for Intraoperative Perfusion Assessment in Women with Ureteral Endometriosis: A Preliminary Study. J Minim Invasive Gynecol 2021;28:42-9. [Crossref] [PubMed]
47. Di Maida F, Lambertini L, Grosso AA, et al. Urinary Tract Endometriosis: How to Predict and Prevent Recurrence after Primary Surgical Excision. J Minim Invasive Gynecol 2022;29:1178-83. [Crossref] [PubMed]
48. Kapoor R, Stratopoulou CA, Dolmans MM. Pathogenesis of Endometriosis: New Insights into Prospective Therapies. Int J Mol Sci 2021;22:11700. [Crossref] [PubMed]
49. Rocha MA, Mendes G, Castro LF, et al. Outcomes of Urinary Tract Endometriosis-Laparoscopic Treatment: A 10-Year Retrospective Study. J Clin Med 2023;12:6996. [Crossref] [PubMed]
50. Nezhat C, Falik R, McKinney S, et al. Pathophysiology and management of urinary tract endometriosis. Nat Rev Urol 2017;14:359-72. [Crossref] [PubMed]
51. Efe E, Bakacak M, Serin S, et al. Hormonal treatment for severe hydronephrosis caused by bladder endometriosis. Case Rep Urol 2014;2014:891295. [Crossref] [PubMed]
52. Bai Y, Li Y, Li Q, et al. Severe Ureteral Endometriosis Complicated with Hydronephrosis: A Case Report. Am J Case Rep 2022;23:e937172. [Crossref] [PubMed]
53. Saavalainen L, Heikinheimo O, Tiitinen A, et al. Deep infiltrating endometriosis affecting the urinary tract-surgical treatment and fertility outcomes in 2004-2013. Gynecol Surg 2016;13:435-44. [Crossref] [PubMed]
54. Katsikatsos P, Douroumis K, Goutas D, et al. Renal Endometriosis Mimics Renal Cell Carcinoma in a Hypoplastic Kidney: A Case Report. Cureus 2024;16:e55280. [Crossref] [PubMed]
55. Alsahabi J, Dendini M, Al-Zahrani EF, et al. Paraurethral Endometriosis as a Common Pathology in an Uncommon Location: A Case Report and a Review of the Literature. Cureus 2023;15:e35024. [Crossref] [PubMed]
56. Mandai M, Osuga Y, Hirata T, et al. Cancers associated with extraovarian endometriosis at less common/rare sites: A nationwide survey in Japan. J Obstet Gynaecol Res 2020;46:917-23. [Crossref] [PubMed]