# The Silent Strangulation: Post-hysterectomy Ureteral Endometriosis Masquerading as Iatrogenic Injury

## TL;DR

A rare case of ureteral endometriosis, mistaken for surgical injury after a hysterectomy, highlights the need for careful preoperative evaluation to prevent kidney damage.

## Contribution

This case emphasizes the importance of preoperative ureteral assessment in patients with extensive endometriosis to avoid misdiagnosis and renal complications.

## Key findings

- Ureteral endometriosis can remain asymptomatic until post-surgical changes cause obstruction.
- Postoperative fibrosis may worsen ureteral constriction, leading to acute symptoms.
- Early recognition of ureteral involvement is crucial to prevent irreversible kidney injury.

## Abstract

Ureteral endometriosis (UE) is a rare but potentially devastating manifestation of deep infiltrating endometriosis, often remaining asymptomatic until irreversible renal damage occurs. We present the case of a 42-year-old woman with a long-standing history of obstetric loss and severe menorrhagia. She underwent a total abdominal hysterectomy (TAH) for extensive adenomyosis with multifocal pelvic endometriosis, confirmed on histopathology. While her uterine symptoms resolved postoperatively, she returned three months later with persistent right-sided flank and groin pain. Given her recent surgery, initial clinical suspicion centered on iatrogenic ureteral injury or recurrent urinary tract infection, leading to repeated courses of antibiotics with no relief. Advanced imaging ultimately revealed Grade IV hydroureteronephrosis with characteristic distal ureteral tapering, confirming mechanical obstruction. Importantly, the obstruction was not surgical in origin; it reflected the progression of deep infiltrating endometriosis involving the ureteral adventitia, likely present before the hysterectomy. Postoperative fibrosis may have exacerbated the ureteral constriction, precipitating the acute presentation. This case highlights a critical diagnostic pitfall: UE can remain clinically silent until post-surgical changes unmask obstruction, mimicking more common postoperative complications. We advocate for proactive preoperative evaluation of the ureters in patients with extensive endometriosis to prevent silent loss of renal function. Even after definitive uterine surgery, clinicians must maintain a high index of suspicion for ureteral involvement. Early recognition and intervention are essential to prevent irreversible kidney injury.