Case Report:
A 35-year-old nulligravida woman presented at the emergency department with acute right-sided flank pain radiating to the groin. Her last menstrual period was three weeks prior to presentation, and she had no significant medical or surgical history. Physical examination revealed right costovertebral angle (CVA) tenderness and a palpable mass in the right adnexa and the patient had experienced two episodes of non-bilious emesis. Laboratory evaluation, including renal function tests, was unremarkable. A computed tomography (CT) study of the abdomen and pelvis showed a remarkably large mass in the right adnexa (Fig. 2,3). The mass exhibited characteristics consistent with a large teratoma, measuring approximately 7 x 7 cm, containing fat, soft tissue, calcification, and fluid (Fig. 2). The teratoma caused displacement of the uterus to the left (Fig. 2) and resulted in pyelocalyceal rupture on the right side. This rupture led to the development of a urinoma in the right perinephric region (Fig. 1). A renal ultrasound confirmed the renal involvement, showing increased cortical echogenicity, parenchymal hyperemia, and a small complex multiseptated right perinephric fluid collection consistent with a urinoma (Fig. 1). Given the patient’s clinical presentation and imaging findings, a multidisciplinary team was involved in the management. The patient underwent a robot-assisted right salpingo-oophorectomy, cystoscopy, and retrograde cystogram. Remarkably, despite her lack of prior surgical history, the surgical procedure revealed the necessity for extensive adhesiolysis due to the presence of dense adhesions encasing the right adnexa. These adhesions, possibly resultant from inflammatory processes, previous pelvic infections, or the teratoma itself, posed a significant challenge. The urologist’s insights during the operation indicated that the ureter was not just displaced but compressed due to the mass, which in turn led to the renal complications. This compression can be attributed to the significant displacement of the uterus caused by the teratoma. This displacement might have led to the kinking of the ureter, and the potential inflammatory or reactive changes in the surrounding tissues could have contributed to its adherence and impact. To ensure free urine flow and mitigate further postoperative complications, a temporary ureteral stent was placed. The teratoma was successfully dissected, revealing a 7 x 7 cm mass with hair present. No ascites or peritoneal implants were observed. The pathology report confirmed the diagnosis of a mature and multi-tissue ovarian teratoma. The patient had an uncomplicated postoperative course and recovered well. Follow-up evaluations were scheduled to monitor her progress.