Design: Case report

Setting: Academic medical center

Patients or Participants: 42-year-old G0 with a remote history of total hysterectomy and left salpingo-oophorectomy for endometriosis who presented with left flank pain. Pelvic imaging demonstrated left hydronephrosis and a 3.6 cm cystic lesion in the left adnexa at the level of the dilated ureter, concerning for ovarian remnant.

Interventions: Given severe pain and hydronephrosis, the patient had a left percutaneous nephrostomy tube placed preoperatively. She elected to undergo minimally invasive excision of the ovarian remnant and removal of the contralateral ovary to limit the risk of endometriosis recurrence. Intraoperatively, we determined that left ureteral reimplantation was warranted due to extrinsic ureteral endometriosis and patient’s desire for complete resection of all visible disease.

Measurements and Main Results: We discuss the following surgical principles for the management of ovarian remnant syndrome in patients with advanced endometriosis: 1) comprehensive evaluation of distorted anatomy and identification of endometriosis, 2) retroperitoneal approach involving complete ureterolysis, 3) proximal division of the ovarian vessels at their origin, 4) removal of sub-ovarian adhesions and adequate peritoneal margins along the external iliac vessels, and 5) excision of other sites of abdominopelvic endometriosis.

Conclusion: We present an evidence-based approach to the management of ovarian remnant syndrome to prevent recurrence in patients with advanced endometriosis. This patient was discharged home in good condition with pain resolved at her postoperative visit.