Transplant ureteric stenosis complicating laparoscopic recurrent inguinal hernia repair

OUP accepted manuscript

Since transplanted kidney allografts are standardly placed in a heterotopic pelvic position, any surgical intervention in the pelvis carries the potential risk for allograft injury. A 41-year-old female G4P2 with history of prior kidney transplants presented for an elective cesarean sections (CS). During the CS, profound bleeding was encountered and was later realized to be from the transplanted kidney allograft. A complete transection of the upper pole with the injury extending to the hilar structures was noted. Careful intraoperative evaluation led to the decision favoring a salvage attempt of the remaining part of the allograft. The patient continues to enjoy sufficient allograft function 6 months after the incident. To conclude, although CS after kidney transplantation is considered safe, the risk of allograft injury remains possible with potentially catastrophic consequences. This case highlights the importance of rapid surgical expertise and appropriate preoperative evaluation, preparation and planning.

A Management of Ureteral Obstruction After Lichtenstein Tension-Free Hernia Repair in a Kidney Transplant Recipient: A Case Report

BACKGROUND

The number of renal transplants has been increasing in recent years. Recent literature data show that abdominal operations performed on patients who undergo renal transplant have higher morbidity and mortality.

CASE PRESENTATION

A 49-year-old man who had received a renal transplant from a living donor 19 years ago underwent Lichtenstein tension-free hernia repair. Anuria was observed after the operation. Renal ultrasound demonstrated massive hydronephrosis and an elevated serum creatinine level (4.6 mg/dL). It was thought that the ureter may have been obstructed because of the operation, and, with the patient under local anesthesia, all sutures and polypropylene mesh were removed. Urine output was still not present, so a percutaneous nephrostomy catheter was inserted to normalize renal function. The patient underwent reoperation under general anesthesia 45 hours after the first operation. It was observed that the ureter was ligated during high ligation. The ureter was released, and no additional intervention was performed. The patient was discharged 6 days later with a return to basal creatinine level and a percutaneous nephrostomy catheter. The patient was hospitalized twice for severe urinary tract infection and urosepsis within 3 months and received appropriate treatment. The patient has had an uneventful postoperative course for 18 months.

DISCUSSION

Inguinal hernia repair is seen as a safe surgical procedure, but the risk of emerging urological complications is higher in patients with renal transplant. Imaging before surgery to identify the anatomy of the kidney and ureter may be useful. Delicate dissection of the extraperitoneal area during the operation will reduce surgical complications.

Rapidly Progressive Invasive Urothelial Carcinoma With Flat and Infiltrative Growth Pattern in the Graft Kidney After Living-Related Kidney Transplantation: A Case Report

BACKGROUND

Because immunosuppression is necessary for kidney transplant recipients, malignant tumorigenesis of recipient organs is a concern; however, few studies have discussed the malignant alteration of transplanted grafts that have been functional for a long time. In addition, a urothelial carcinoma (UC) in transplanted kidney graft is a rare disease.

CASE REPORT

A 62-year-old man had end-stage renal failure 31 years ago and received a kidney transplant from his father. Acute renal failure due to obstruction of the transplanted ureter was diagnosed. Ultrasound, ureterogram, and non-enhanced computed tomography scans revealed no obvious evidence of any neoplastic lesion. We treated the obstruction and hydronephrosis with transplant ureter stenting. However, the regional lymph nodes enlarged, and it became necessary to change the ureteral stent frequently because of stent stenosis; therefore, he underwent lower transplant ureteral resection and reconstruction. Histopathology confirmed a UC with a flat and infiltrative growth pattern. The patient then underwent graftectomy including right external iliac vein resection and reconstruction; however, because of numerous metastatic nodules, radical surgery could not be performed. The patient subsequently died because of septic shock after the second surgery.

CONCLUSION

We report a case of an invasive UC with a flat and infiltrative growth pattern derived from a transplant kidney graft that occurred 31 years after a living-donor transplant that could not be treated immediately and was difficult to diagnose.

Internal inguinal hernia on the transplant side after kidney transplantation: a case report

The patient was a 52-year-old man who presented with right inguinal swelling and pain. He had undergone kidney transplantation in 2005 and bypass surgery using a vascular prosthesis from the left axillary artery to the bilateral femoral arteries in 2008. The vascular prosthesis had invaded the right inguinal canal ventrally. The transplanted ureter had a hazy appearance on a non-enhanced abdominal CT scan. A Lichtenstein operation was performed under a diagnosis of inguinal hernia. A skin incision with pulling of tissue and subcutaneous fat was devised to avoid exposure of the vascular prosthesis. The inguinal canal and spermatic cord were found to have coalesced. The hernia was diagnosed as a supravesical hernia, class II-1. This case shows that a Lichtenstein operation is a suitable procedure for avoidance of damage to the transplanted ureter in treatment of a transplant-side inguinal hernia in a kidney transplant recipient.

First Case Report of Acute Renal Failure After Mesh-Plug Inguinal Hernia Repair in a Kidney Transplant Recipient

Acute renal failure due to ureter compression after a mesh-plug inguinal repair in a kidney transplant recipient has not been previously reported to our knowledge. A 62-year-old man, who successfully underwent kidney transplantation from a deceased donor 6 years earlier, was admitted for elective repair of a direct inguinal hernia. The patient underwent an open mesh-plug repair of the inguinal hernia with placement of a plug in the preperitoneal space. We did not observe the transplanted ureter and bladder during dissection of the inguinal canal. Immediately after surgery, the patient became anuric, and a graft sonography demonstrated massive hydronephrosis. The serum creatinine level increased rapidly, and the patient underwent an emergency reoperation 8 hours later. During surgery, we did not identify the ureter but, immediately after plug removal, urine output increased progressively. We completed the hernia repair using the standard technique, without plug interposition, and the postoperative course was uneventful with complete resolution of graft dysfunction 3 days later. Furthermore, we reviewed the clinical features of complications related to inguinal hernia surgery. An increased risk of urological complications was reported recently in patients with a previous prosthetic hernia repair undergoing kidney transplantation, mainly due to the mesh adhesion to surrounding structures, making the extraperitoneal dissection during the transplant surgery very challenging. Moreover, older male kidney transplant recipients undergoing an inguinal hernia repair may be at higher risk of graft dysfunction due to inguinal herniation of a transplanted ureter. Mesh-plug inguinal hernia repair is a safe surgical technique, but this unique case suggests that kidney transplant recipients with inguinal hernia may be at higher risk of serious urological complications. Surgeons must be aware of the graft and ureter position before proceeding with hernia repair. A prompt diagnosis with graft sonography and abdominal computed tomography scan and emergency surgery may avoid the need for nephrostomy and may resolve graft dysfunction more rapidly.

Inguinal Herniation of a Transplant Ureter: Lessons Learned From a Case of "Water Over the Bridge"

Inguinal herniation of the transplant ureter is rare, and there is a paucity of reports in the literature. Herniation is usually secondary to implanting a long redundant ureter and may be precipitated by its course over the spermatic cord. Most often, there is loss of the allograft owing to delayed presentation and chronic ureteric obstruction. Here, we report a case of inguinal herniation of a transplant ureter with obstruction and graft dysfunction. A 72-year-old man presented 9 years after deceased-donor kidney transplant, with progressive graft dysfunction and a symptomatic right inguinal hernia. A nephrostogram and subsequent surgery confirmed herniation of a loop of transplant ureter into the inguinal canal with a proximal dilated ureter and hydronephrosis. A long and redundant ureter had been anastomosed "over" the spermatic cord to the bladder during the original operation. The ureter was shortened by excising the distal segment, and the proximal dilated ureter was anastomosed to the bladder passing it "underneath" the spermatic cord. We used a Vicryl (polyglactin 910) mesh to repair the hernia. The graft function improved to baseline levels after the nephrostomy and remained stable after the surgery. This case emphasizes the need to keep the ureter short, and the importance of passing it underneath the spermatic cord before anastomosing to the bladder. Transplant and general surgeons should be aware of such presentations of graft dysfunction with inguinal hernia to avoid delayed diagnosis and graft loss.