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.