Chasing the hidden ovary: Repeated battle with ovarian remnant syndrome, ureteric stenosis and reimplantation using robotics & ICG fluorescence

Background: Ovarian Remnant Syndrome (ORS) is a rare but clinically significant condition where ovarian tissue persists after oophorectomy. This retained tissue remains functional, potentially leading to complications such as chronic pelvic pain, cyst formation, hormonal activity and ureteric obstruction. ORS is particularly challenging in patients with severe pelvic adhesions, endometriosis or a history of multiple gynaecologic surgeries. Case: A 39-year-old woman with a history of total abdominal hysterectomy with ovarian preservation for early cervical cancer (FIGO 1A1) presented several years later with pelvic pain, which initially responded to GnRH analogues. Later, she underwent laparoscopic bilateral salpingo-oophorectomy and was discharged on Tibolone. After 8 weeks, she presented to A&E with severe pain. Imaging revealed 5 cm cystic mass compressing the distal ureter, leading to moderate hydronephrosis. Ureteric stenting was performed, and Tibolone was discontinued. Hormonal studies confirmed premenopausal levels, diagnosing ovarian remnant syndrome (ORS). She subsequently underwent robotic oophorectomy with ureteric shaving. Histology confirmed endometriosis. However, postoperative persistence of the ovarian remnant cyst, ureteric stricture and hydronephrosis resulted in eventual nephrostomy after stent removal. She ultimately underwent robotic ureteroneocystostomy with ICG-guided ureteric identification. Conclusion: This case highlights the challenges of managing recurrent ORS with ureteric involvement. Robotic surgery with ICG guidance was crucial in enhancing surgical precision and preserving renal function.