Refractory Endometriosis Managed with Multiple Surgeries: Complete Symptom Resolution After Third Laparoscopic Intervention

Endometriosis is a chronic, estrogen-dependent inflammatory disorder characterized by the presence of endometrial-like tissue outside the uterine cavity. It affects approximately 10% of women of reproductive age and is a leading cause of chronic pelvic pain (CPP), dysmenorrhea, and infertility.[] Despite advances in medical therapy, including hormonal suppression and analgesics, recurrence rates remain high, and many patients experience persistent or refractory symptoms.[] Surgical intervention, particularly laparoscopic excision of endometriotic lesions, is considered the gold standard for diagnosis and treatment.[] However, even after surgery, recurrence of pain and disease is common, with reported rates ranging from 20% to 40% within 5 years.[,] Repeated surgeries pose additional challenges, including adhesions, reduced ovarian reserve, and increased operative risk. Nevertheless, in selected patients with severe or recurrent disease, comprehensive surgical excision may provide durable symptom relief and improved quality of life. CPP is defined as noncyclic pain of at least 6 months’ duration localized to the pelvis, anterior abdominal wall at or below the umbilicus, lumbosacral back, or buttocks, and severe enough to cause functional disability or require medical care.[] The condition affects between 2% and 27% of women worldwide, with prevalence estimates of approximately 4% in developed countries.[] CPP accounts for a substantial proportion of gynecological consultations, almost similar to conditions such as abnormal uterine bleeding and infertility. The etiologies of CPP are diverse, encompassing gynecological (endometriosis, adenomyosis, pelvic adhesions), urological (interstitial cystitis, ureteric pathology), gastrointestinal (irritable bowel syndrome, diverticulitis), musculoskeletal, and psychosocial factors.[] Even when abnormalities such as adhesions or endometriosis are detected, surgical interventions often yield unsatisfactory outcomes.[] Iatrogenic causes, particularly retained surgical materials, are rarely considered. Surgical clips, sutures, and meshes are widely used in minimally invasive procedures. While generally safe, inadvertent retention or migration of these materials can lead to delayed complications including pain, infection, fibrosis, and organ dysfunction. Hem-o-lok® clips, polymer devices commonly used for vascular and ureteric ligation, have been associated with complications such as clip migration, erosion, and foreign body reactions. Reports of retained clips as a cause of CPP are extremely uncommon, making this case noteworthy. This case report describes the clinical course of a woman with refractory CPP due to endometriosis and a retained Hem-o-lok® clip following robotic ureteric reimplantation, undergoing three surgeries before achieving complete and sustained resolution of symptoms. CASE REPORT A woman in her 40s presented to the gynecology outpatient clinic with complaints of chronic, noncyclic pelvic pain, dysmenorrhea and dyspareunia persisting for about 12 years. Over the years, she had undergone multiple medical therapies, including hormonal suppression (combined oral contraceptives, progestins, Gonadotropin releasing hormones analogues), analgesics, and empiric antibiotics. But the disease progressed with endometriotic nodule deposits around the ureter, leading to hydroureteronephrosis. She had a surgical history of hysterectomy along with bilateral salpingo-oophorectomy and Robotic Boari flap ureteric reimplantation with psoas hitch performed 5 years earlier for periureteric endometriosis. However, due to persistence of symptoms and secondary complications of endometriosis, she underwent right nephrectomy 4 years earlier in view of a nonfunctioning kidney. Both procedures were uneventful, and she recovered without immediate complications. After a few months following the second surgery, she reported progressive worsening of the pain, significantly impairing her quality of life over the past 2 years. This pain was described as deep, aching, and localized to the right pelvic region, exacerbated during intercourse and prolonged sitting. The abdominal examination was not significant. On bimanual examination of the patient, a 3 cm × 2 cm nodule could be felt in the right lateral fornix, which was tender on touch. The vault was healthy. Investigations Laboratory tests including complete blood count, renal function tests, and inflammatory markers were within normal limits. Imaging investigations including ultrasound and computed tomography were inconclusive, revealing only nonspecific fibrotic changes. Pelvic MRI demonstrated subtle fibrotic changes near the right parametrium but no definitive mass or endometriotic lesion. Given the refractory nature of her symptoms, diagnostic laparoscopy was planned. Treatment Diagnostic laparoscopy revealed dense fibrotic tissue near the lateral bladder wall, right parametrium, and right fornix and multiple endometriotic deposits over the bladder. Careful dissection identified a retained Hem-o-lok® clip embedded within the fibrotic tissue. Adjacent remnants of the excised ureter were also noted in the fibrotic mass [Figure 1]. Meticulous adhesiolysis was performed using sharp and blunt dissection to restore normal pelvic anatomy. The retained clip was carefully mobilized by dissecting surrounding fibrotic tissue under direct visualization, ensuring preservation of adjacent bladder and parametrial structures. Once freed, the clip was excised and removed intact. Endometriotic deposits present over the bladder wall and other peritoneal deposits were carefully excised. Hemostasis was achieved with bipolar coagulation, and the bladder integrity was confirmed intraoperatively. The remainder of the pelvic cavity appeared normal, with no additional lesions identified. Outcome and follow-up The patient recovered uneventfully and experienced marked symptomatic relief within weeks of surgery. Her Visual Analog Scale score for pelvic pain improved from 8/10 preoperatively to 2/10 at 6 weeks, and remained at 0–1/10 at 6 months. Dyspareunia resolved completely by 3 months, and her World Health Organization Quality of Life – BREF (WHOQOL-BREF) score rose from 42/100 before surgery to 78/100 at 6 months, reflecting significant gains in physical, psychological, and social wellbeing. At 6-month follow-up she remained painfree, with sustained resolution of dyspareunia and improved quality of life. The followup was extended to 12 months postoperatively, during which she continued to be asymptomatic, with no recurrence of pain or endometriotic lesions noted on clinical evaluation.

CPP and endometriosis remain among the most challenging gynecological disorders due to their recurrent nature. In the present case, the patient had a long-standing history of refractory CPP and dyspareunia, despite extensive medical therapy and multiple surgical interventions including hysterectomy, bilateral salpingo-oophorectomy, and ureteric reimplantation. The persistence of symptoms following these procedures highlights the difficulty in achieving complete relief in advanced endometriosis. A unique aspect of this case was the identification of a retained Hem-o-lok® clip embedded within dense fibrotic tissue near the bladder wall and parametrium. While retained surgical materials are rarely reported as a cause of CPP, they can act as persistent irritants, driving fibrosis, inflammation, and pain.[] There are only isolated reports documented in the literature of retained surgical materials causing CPP.[] Most published cases describe foreign bodies leading to urinary tract complications such as hematuria, recurrent infections, or obstructive uropathy, rather than isolated pelvic pain.[] Importantly, this case of surgical material embedded near the bladder is novel because cliprelated CPP occurring in the absence of urinary tract symptoms is exceedingly rare. The inconclusive imaging findings further highlight the limitations of conventional modalities in detecting small foreign bodies or subtle fibrotic changes. Diagnostic laparoscopy, therefore, proved invaluable for direct visualization and definitive therapeutic intervention. The complete resolution of symptoms following clip excision and adhesiolysis emphasizes the importance of considering iatrogenic causes in the differential diagnosis of refractory CPP, particularly in patients with a history of multiple pelvic surgeries. While endometriosis was the primary pathology in this patient, the retained foreign body served as a secondary pain generator, complicating the clinical picture. This case reinforces the principle that persistent or unexplained pelvic pain warrants a thorough evaluation, including the possibility of retained surgical materials. From a broader perspective, this case highlights the multifactorial nature of CPP, where endometriosis, adhesions, and iatrogenic factors may coexist and contribute to persistent symptoms. It underscores the limitations of imaging, as small foreign bodies or subtle fibrotic changes may evade detection, thereby necessitating surgical exploration in refractory cases. Laparoscopy continues to play a pivotal role as both a diagnostic and therapeutic tool, offering direct visualization and the opportunity for definitive management. Finally, the case emphasizes the importance of surgical vigilance, where careful intraoperative assessment and meticulous technique are essential to minimize the risk of retained materials and ensure durable symptom relief. Ultimately, this case demonstrates that even in patients with extensive surgical histories and refractory symptoms, targeted surgical intervention can provide complete and sustained relief, significantly improving quality of life. The etiology of CPP is notoriously difficult to diagnose and manage. The heterogeneity of etiologies, overlapping symptomatology, and frequent absence of definitive findings complicate evaluation. In nearly 40% of patients undergoing laparoscopy, no abnormality is identified.[] Even when adhesions or endometriosis are found, surgical outcomes are often unsatisfactory, with high rates of persistent or recurrent pain. This case illustrates the importance of considering iatrogenic causes in the differential diagnosis, particularly in patients with prior pelvic surgery. Foreign-body retention is a recognized but rare complication of surgery.[] Common retained materials include sponges, sutures, and clips. Clinical manifestations vary from asymptomatic to severe pain, infection, or organ dysfunction.[] Hem-o-lok® clips are nonabsorbable polymer devices widely used for vascular and ureteric ligation in laparoscopic and robotic surgery. While generally safe, few complications have been reported such as clips may migrate into adjacent organs such as the bladder or urethra, causing hematuria, stone formation, or obstruction. Sometimes inadvertent retention of clips in fibrotic tissue can incite chronic inflammation and pain.[] Clips may erode into hollow viscera, leading to fistulae or infection. In the index case, the retained clip acted as a chronic irritant, inciting fibrosis and mimicking gynecological pathology. The retained clip likely contributed to pain via mechanical irritation of adjacent tissues, a chronic inflammatory response leading to fibrosis and distortion of pelvic anatomy, causing dyspareunia. Removal of the clip and endometriotic deposits and adhesiolysis alleviated these mechanisms, resulting in complete symptomatic relief. Reports of retained Hem-o-lok® clips causing CPP are scarce. Most literature describes clip migration into urinary tract structures, presenting with hematuria, recurrent urinary tract infections, or stone formation.[] Cases of clip-related pelvic pain without urinary symptoms are exceedingly rare, underscoring the novelty of this presentation. This case has several important implications. In patients with refractory CPP and prior pelvic surgery, retained surgical materials should be considered, as conventional imaging may fail to detect small foreign bodies embedded in fibrotic tissue. Diagnostic laparoscopy remains invaluable in unexplained CPP, allowing direct visualization and therapeutic intervention. Meticulous intraoperative technique and thorough review of surgical materials are essential to prevent retention.

This case highlights the diagnostic and therapeutic challenges in managing CPP associated with endometriosis, particularly in patients with extensive surgical histories. While endometriosis was the primary pathology, the presence of a retained Hem-o-lok® clip acted as a secondary pain generator, perpetuating symptoms despite prior interventions. The complete resolution of pain following clip excision and adhesiolysis underscores the importance of maintaining a high index of suspicion for iatrogenic causes in refractory cases. Diagnostic laparoscopy remains indispensable, both for direct visualization and definitive treatment, when conventional imaging is inconclusive. Ultimately, meticulous surgical technique and comprehensive evaluation are essential for achieving durable symptom relief and improving quality of life in women with complex endometriosis-related CPP. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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