Ureteral Injury During Laparoscopic Hysterectomy in Korea: A 250 Million Won Court-Mediated Resolution

Case Overview

A woman in her forties visited the obstetrics and gynecology department of a large hospital with irregular menstrual periods and pelvic pain. Imaging suggested a cyst on her left ovary and adenomyosis, a condition in which tissue resembling the uterine lining grows into the muscular wall of the uterus. Her physician recommended laparoscopic surgery, describing it as a relatively safe approach compared with open abdominal surgery. She underwent a laparoscopic operation to remove her uterus together with her left ovary and left fallopian tube.

Her kidney function had been normal before the procedure. After the operation, she reported discomfort in her left lower back. The hospital discharged her two days later without ordering further testing. When she raised the same symptom at a follow-up appointment, no additional investigations were arranged. A CT scan taken about two months after surgery was initially interpreted as normal. A later review by a nephrologist showed that her left kidney had already begun to swell as urine backed up, a condition known as hydronephrosis.

Her renal function continued to deteriorate. About three years after the operation, imaging revealed that her left ureter had narrowed and that the left kidney was severely swollen and shrunken. Around two months after surgery her blood pressure had also risen to the point that she needed medication; only years later was the hypertension connected to the kidney problem. She was advised to keep monitoring her condition. About seven and a half years after the surgery, she was diagnosed with stage 3 chronic kidney disease and loss of function in her left kidney.

Taeshin Law Firm brought a damages claim against the hospital on her behalf. The court handled the matter through mediation and issued a decision in lieu of mediation ordering the hospital to pay 250 million won.

Background

The uterus, ovaries and ureters sit close together in the pelvis, and gynecologic surgery accordingly carries a recognized risk of injury to the urinary tract. The ureter is the narrow tube that carries urine from the kidney to the bladder. It runs behind the peritoneum, the membrane lining the abdominal cavity, and passes near the uterine artery and the structures that are divided during a hysterectomy. Because it lies deep in the surgical field, an injury to it may not be visible at the time of the operation.

The client's preoperative workup had shown normal kidney function, with no abnormality in her blood tests or pelvic CT. The operation was performed laparoscopically, through small incisions using a camera and specialized instruments, rather than through an open abdominal incision. The surgeon removed the uterus, the left ovary and the left fallopian tube.

The postoperative course is central to the case. From the period immediately after surgery, the client felt discomfort in her left lower back. The hospital discharged her after two days without further imaging or specialist assessment. The same complaint was repeated at the outpatient visit, again without additional testing. When a CT scan was performed about two months later, the report was initially read as normal, but a subsequent review showed hydronephrosis on the left side.

Over the following years, laboratory values reflected worsening kidney function, including proteinuria. About three years after surgery, imaging confirmed ureteral narrowing and marked swelling and shrinkage of the left kidney. Her blood pressure had begun to rise within roughly two months of the operation and required medication; the connection to the renal problem was recognized only much later. She received advice to continue observation, and ultimately, about seven and a half years after the operation, was diagnosed with stage 3 chronic kidney disease with loss of left kidney function. Litigation followed about eight years after the surgery.

Medical Issue

The medical question at the center of the case was whether the left ureter was injured during the laparoscopic hysterectomy. Ureteral injury is a known complication of gynecologic surgery, particularly hysterectomy, and it is often silent when it occurs. A ligature, a suture, a thermal injury from electrocautery, or direct trauma can compromise the tube without producing immediate, unmistakable symptoms. Instead, the obstruction may reveal itself later through flank pain, hydronephrosis and progressive loss of kidney function.

The timing of diagnosis matters greatly. If a ureteral obstruction is recognized while the kidney is still functioning, the obstruction can often be relieved and the kidney preserved. If it is missed, prolonged back-pressure can damage the kidney irreversibly. Because a patient recovering from abdominal or pelvic surgery is already experiencing incisional pain, a new pain in the flank or lower back can be mistaken for ordinary postoperative discomfort. For that reason, such pain is a recognized warning sign that calls for investigation.

In this case, the client's symptoms began immediately after surgery, and imaging about two months later showed hydronephrosis, yet the significance of those findings was not acted upon for years. The medical issue was therefore twofold: whether the ureter was injured during the operation itself, and whether the subsequent failure to investigate and treat the obstruction caused or worsened the loss of kidney function.

Key Legal Issues

Three issues framed the claim.

First, causation. The claim had to establish that the ureteral injury occurred during the hysterectomy. The long interval between the operation and the lawsuit made this the most demanding part of the case. The client's preoperative kidney function had been normal, and no other explanation for the ureteral narrowing had been identified. Taeshin Law Firm relied on the chronological sequence of the records — normal preoperative studies, immediate postoperative flank discomfort, hydronephrosis on later imaging, and steadily worsening renal values — together with the absence of any alternative cause.

Second, delayed diagnosis and treatment. Even accepting that a ureteral injury can be an inherent risk of hysterectomy, the claim argued that the hospital's response to the postoperative symptoms was negligent. The client reported flank discomfort immediately after surgery and again at follow-up, yet no appropriate testing was arranged. After hydronephrosis and ureteral narrowing were documented, no definitive investigation or corrective treatment, such as ureteral dilation or reconstructive surgery, was undertaken. According to the claim, this lost the opportunity to preserve kidney function.

Third, damages. The claim had to quantify the loss caused by the permanent impairment of one kidney. Taeshin Law Firm relied on a disability assessment that placed the loss of earning capacity at 54 percent and calculated lost income to working age on the basis of the client's actual income records.

Taeshin's Approach

Taeshin Law Firm built the case from the medical record rather than from the operation in isolation. The team arranged the records in chronological order to show a continuous chain: normal kidney function before surgery, left flank discomfort immediately afterward, hydronephrosis on imaging about two months later, proteinuria and worsening renal values thereafter, and documented ureteral narrowing and kidney atrophy about three years after the operation. The firm emphasized that no cause other than the surgery could account for the stricture, and it submitted a recording of a conversation in which medical staff referred to a ureteral injury.

The firm also supported the causal explanation with medical literature and comparable decisions. The literature indicates that more than half of ureteral injuries occurring during surgery are associated with gynecologic procedures, and that hysterectomy, particularly the stage at which the uterine artery is dissected and ligated, is a common setting for such injuries. The firm presented decisions involving ureteral injuries detected late after laparoscopic hysterectomy, which described how a thermal or operative injury can later manifest as obstruction and hydronephrosis. Those materials helped explain a mechanism that the records alone could not show.

On the issue of delay, the firm argued that the hospital should have investigated the postoperative flank pain rather than discharging the client without further testing. It pointed to the recognized principle that flank or lower-back tenderness after pelvic surgery should raise suspicion of ureteral injury, precisely because the symptoms are easily masked by wound pain. It further argued that once hydronephrosis and stricture had been confirmed, the failure to perform definitive testing and corrective treatment allowed the kidney to deteriorate beyond recovery.

Finally, the firm translated the medical findings into a damages claim. Using the disability evaluation standards, it assessed the loss of earning capacity at 54 percent and calculated lost income to working age from the client's actual income data.

Outcome

The court dealt with the case through mediation and issued a decision in lieu of mediation. Under Korean civil procedure, when the parties cannot agree on a settlement, the court may set the terms itself in a decision. If neither party objects within the statutory period, the decision becomes final and concludes the dispute in a manner comparable to a settlement.

The decision required the hospital to pay the client 250 million won. The client waived the remainder of her claim. Both sides confirmed that no further claims existed between them regarding this surgery, and each side bore its own litigation costs.

A court-ordered mediation decision is not a full judgment resolving every factual and legal allegation. The outcome should therefore be understood as the terms the court considered appropriate to resolve the dispute, rather than as a finding on each element of the claim.

What This Case Shows

The case illustrates why postoperative flank pain deserves attention after pelvic surgery. Ureteral injury can occur without dramatic signs, and the symptoms it produces may resemble ordinary recovery pain. When the injury is recognized early, treatment can often preserve the kidney; when it is missed, the damage can become permanent.

It also shows that a long interval between an operation and a lawsuit does not by itself prevent a medical malpractice claim in Korea. Causation can be established from the medical records, the course of symptoms, the absence of alternative explanations, and the medical literature, even years after the event.

The case further demonstrates that delayed diagnosis can be treated as negligence separate from the original surgical complication. A hospital's failure to investigate and treat a recognized warning sign may support a claim in its own right, and can amount to hospital negligence.

For patients, the practical lesson is to obtain and preserve medical records, including imaging reports and follow-up notes, and to ask how postoperative symptoms are being explained. For foreign patients and international families, the case also shows how complex medical malpractice claims in Korea can be resolved through court-mediated decisions rather than a full trial.