Elsevier

Urology

Volume 70, Issue 6, December 2007, Pages 1224.e1-1224.e3
Urology

Case report
Inguinal Herniation of a Transplant Ureter: Rare Cause of Obstructive Uropathy

https://doi.org/10.1016/j.urology.2007.09.054Get rights and content

We present a rare case of late renal allograft failure from ureteral obstruction resulting from inguinal herniation. A 72-year-old man presented with an elevated creatinine and hydroureteronephrosis of a transplanted kidney on ultrasound. Noncontrast computed tomography demonstrated an inguinal hernia containing ureter, and a nephrostomy tube was placed. The hernia and ureter were temporarily reduced during antegrade stent insertion. Creatinine normalized and we performed inguinal herniorrhaphy with polypropylene mesh. The ureter was not reimplanted. Renal function remained stable after nephrostomy tube removal. Simple herniorrhaphy without ureteral reimplantation may fix the case of ureteral obstruction from inguinal herniation.

Section snippets

Case Presentation and Management

A 72-year-old man presented in acute renal failure 12 years after receiving a renal transplant from his brother. He complained of shortness of breath and weakness over a 3-day period. He noted decreased urine output throughout this time. The patient had been seen 2 months before presentation and was noted to be in good health with stable renal function. Physical examination revealed an obese man with a small nonreducible left inguinal hernia. His creatinine was elevated to 2.4 mg/dL from a

Discussion

Most cases of late ureteral obstruction after renal transplantation result from obstruction in the lower ureter or ureterovesical junction.1, 4, 10, 11 More often, these are caused by ureterovesical junction obstruction or ischemia of the lower ureter. These patients often present several months to years after surgery. To our knowledge, transplant ureteral obstruction secondary to incarceration within an inguinal hernia is an extremely rare entity, described in the literature twice.8, 12

Our

References (13)

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    The first report of true ureter herniation into the inguinal hernia was by Osman et al [8]. Notably, nearly all subsequent reports continue to refer to the condition as rare [5,9-20]. The majority of case reports describe acute kidney injury as the primary presentation, with decompressive percutaneous nephrostomy tube being the most widely adopted to manage the acute presentation.

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    In many reports, the most used imaging technique was abdominal US for work-up of complications after inguinal hernia repairs, whereas computed tomography and magnetic resonance imaging were also used in some patients. PNCs were placed preoperatively in many patients [8,9,14-20]. Determining possible ureteronephrosis preoperatively may facilitate postoperative management of complications in these cases.

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    Furthermore, the fact that the patient underwent laparoscopy for a right inguinal hernia by the total extraperitoneal repair method also caused difficulty in the diagnosis of UC obstruction. The graft ureter and the internal inguinal ring were structurally close, and many studies have reported that patients who undergo kidney transplants have graft ureter obstructions due to an inguinal hernia [18–20]. We theorized that the transplant and mesh fixation from the total extraperitoneal repair method were in the same space and could have caused the graft ureter obstruction.

  • Management of Spermatic Cord Liposarcoma in Renal Transplant Recipients: Case Report

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    The peculiar therapeutic implications are as follows. First, the preoperative diagnosis was inguinal hernia, and in renal transplant recipients, the presence of a herniated ureter is not uncommon.20,21 Both conditions require immediate repair to avert obstructive uropathy.22–24

  • Scrotal Herniation of the Ureter: A Rare Late Complication After Renal Transplantation

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    Five of them were the primary type,9–13 whereas one presented as a mixed type,8 where the obstructive uropathy was exacerbated by the herniation into the inguinal canal of the ureter, which became tortuous with kinking following a longstanding stricture at the UVJ. Obesity, previous abdominal wall operations positioning of the ureter above the spermatic cord, and excessive length of the ureter at the time of urinary tract construction are considered to be predisposing factors for herniation.8,11–13 Overall, the mean age at diagnosis is 60.6 years, the mean delay of appearance postoperatively is 9.7 years, and the more frequent localization is in the right inguinal canal.

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