• To show surgical management of ureteral obstructing pelvic mass causing hydronephrosis
• To demonstrate approach to complicated hysterectomy in the setting of multiple pelvic abscesses
• To show surgical techniques for restoration of pelvic anatomy

Design: Video

Setting: Operating room

Patients or Participants: 1

Interventions: Robotic assisted total laparoscopic hysterectomy, bilateral salpingectomy, ovarian abscess resection, bladder abscess drainage, extensive enterolysis, bilateral ureterolysis, bowel serosal repair, cystoscopy

Measurements and Main Results: Video abstract

Conclusion:

• Ureteral obstruction is a potentially life-threatening complication that can be caused by pelvic etiologies such as endometriosis, broad ligament fibroids, and large abscesses.
• In our patient, surgical planning with MRI allowed us to plan for extensive adhesions and safely complete the procedure.
• In patients with abscesses, anatomy may be severely distorted and an excellent knowledge of anatomy is required. The first step to successful pelvic surgery will be to restore patient’s anatomy as much as possible.
• An important approach to dissecting adhesions to the rectum is utilizing an EEA sizer to avoid further injury.
• Removal of purulence and abscess walls during the hysterectomy can help the surgeon appreciate the natural anatomical planes for successful surgical procedure.
• Approach of hysterectomy with known ureteral obstruction should include preoperative planning to place bilateral ureteral stents for temporary symptom relief and for anatomic delineation during surgery.
• Visualization of the ureters is important to prevent ureteral injury. Ureteral stents should be left in place for 2-3 months postoperatively to ensure proper healing.