Obturator herniation of the ureter in a renal transplant recipient causing hydronephrosis: perioperative percutaneous management

An unusual ureteral dynamic obstruction in a kidney transplant patient

INTRODUCTION

Ureteral complications are common in kidney transplanted patients; approximately 2.6-15% of patients develop ureteral obstruction/stenosis at some time after surgery, which is one of the most frequent urologic complications. Inguinal herniation of the neoureter is a rare complication but it must be taken into account.

CLINICAL REPORT

We describe the case of a 78-years old male kidney transplanted patient (2004), who was admitted at the emergency room due to abdominal pain and with evidence of acute kidney injury. The ultrasound showed hydronephrosis (grade III) along with ureteral dilatation which ended with an image compatible with a kinking, that was confirmed at the TC and showed that the kneeling was in the right inguinal canal. It was possible, with a manual hernia reduction manoeuvre, to readjust the kneeling of the neoureter resolving the condition temporarily. The patient underwent underwent surgical hernia repair with no complication and complete recovery of renal function.

CONCLUSIONS

When ureter obstruction of the transplanted kidney occurs, it is crucial to resolve the obstruction as soon as possible in order to preserve kidney function. Hernioplastic is an effective way to treat ureter obstruction when it is caused by its herniation.

A preventable cause of transplant hydroureteronephrosis: inguinal herniation of the transplant ureter: case report and review of the literature

BACKGROUND

Transplant ureter obstruction is an important cause of graft loss after kidney transplantation. Most cases occur early after transplantation and are related to surgical causes or ischaemic strictures. Underlying mechanisms of late ureteral obstruction are less well understood.

CASE REPORT

We present the case of a 61-year-old man who showed gradual decline in renal allograft function and hydronephrosis nine years after transplantation, due to an inguinal herniation of the transplant ureter. After urinary diversion using a percutaneous nephrostomy, graft function restored and the patient underwent surgery. The ureter was reduced from the inguinal hernia and re-implanted in the bladder, with primary closure of the abdominal wall defect. Postoperative course was uneventful and serum creatinine returned to baseline levels.

DISCUSSION

Search of relevant literature revealed a number of similar cases, which allowed identification of risk factors associated to the development of uretero-inguinal herniation leading to obstructive nephropathy. Diagnosis of this rare cause of transplant dysfunction and operative treatment strategies are discussed.

CONCLUSIONS

Inguinal herniation of the transplant ureter leading to ureteral obstruction is a rare, probably underreported, cause graft of dysfunction. Therefore, we advocate elective repair of inguinal or incisional hernias in renal transplant recipients.

Not as Rare as Initially Described: Transplant Ureter Incarceration Within Inguinal Hernia. Two Cases, Literature Review, and Management Algorithm

BACKGROUND

Obstructive uropathy after kidney transplant can present as acute kidney injury, urosepsis, and more rarely kidney allograft failure. We present a recent series of 2 cases and a literature review of 1 late etiology of ureteric obstruction: incarceration of the transplant ureter within an inguinal hernia.

METHODS

We reviewed 2 cases of patients with ureteric incarceration in an inguinal hernia after kidney transplant and conducted a contemporary structured literature review. Relevant patient factors, management decisions, operative approaches, and clinical outcomes were abstracted and summarized.

RESULTS

Two cases of ureteric involvement in an inguinal hernia from 2 institutions as well as a literature review of 14 case reports are provided. The clinical features most commonly associated with this condition were male sex, obesity, and decade or more delay between kidney transplantation and presentation. Preoperative management with nephrostomy tube with or without antegrade ureteric stent was most frequently employed. Ultimately, most patients underwent surgical hernia repair, which occasionally required additional surgery for distal ureteric resection or re-anastomosis.

CONCLUSIONS

Incarceration of a transplant allograft ureter in inguinal hernia is likely not as rare as initially described, although a true incidence rate has not been established. This surgically correctible condition most frequently presents as a late complication after kidney transplantation. We present a management algorithm that can be used for the workup and treatment of patients with history of kidney transplant who present with ureteric obstruction owing to incarceration within an inguinal hernia.

Case report of ureter obturator hernia and literature review analysis

BACKGROUND

Ureteral obturator hernia is a rare condition, usually found accidentally during imaging examinations, or found during surgery. Ureteral hernia can easily lead to ureteral obstruction and hydronephrosis. Long-term hydronephrosis may lead to kidney damage and infection, and eventually cause kidney failure. As of December 31, 2020, there are only 2 literature reports.

CASE PRESENTATION

This article reports a 67-year-old female patient with no symptoms. The computed tomography (CT) scan of the urinary system to show the left kidney and ureter had hydrops. The CTU imaging of the urinary tract revealed the left ureter pelvis herniated into the parietal pelvic fascia was accompanied by tortuosity and left hydronephrosis. She underwent laparoscopic abdominal wall hernia repair on April 29, 2020, and she recovered well.

CONCLUSIONS

Ureteral obturator hernia is an uncommon condition. The clinical symptoms are non-specific, including unclear abdominal pain, until the appearance of obstructive diseases of the urinary tract, such as renal insufficiency, urinary tract infection, kidney stones, and uremia. A comprehensive review of the literature shows that it is difficult to make an accurate diagnosis based on physical examination alone.Early urography can improve the possibility of accurate diagnosis. When a patient suffers from impaired renal function, timely surgical treatment can avoid deterioration of renal function.

Graft kidney hydronephrosis caused by transplant ureter inguinal hernia: A case report

RATIONALE

Ureteral obstruction of the graft kidney is a common complication of kidney transplantation. However, ureteral obstruction caused by inguinal hernia has rarely been reported. We present a rare case of ureteral obstruction with allograft dysfunction caused by an inguinal hernia.

PATIENT CONCERNS

A 76-year-old man, who was a renal transplant recipient, presented with bilateral pitting oedema, reduced urine output, and right inguinal hernia.

DIAGNOSES

Abdominal computed tomography revealed severe hydroureteronephrosis of the kidney allograft. A right inguinal hernia with ureteral incarceration was observed.

INTERVENTIONS

The patient underwent graft percutaneous nephrostomy, followed by antegrade insertion of a double-J tube (DJ). Gradual improvement was observed in his renal function. Right inguinal herniorrhaphy was performed 5 days later.

OUTCOMES

The renal function returned to normal after percutaneous nephrostomy and insertion of the DJ. A right inguinal direct-type hernia with ureter adhesion to the hernial sac was observed during the surgery. The posterior wall defect was repaired by the McVay technique. The DJ was removed after 1 month. The patient's renal function remained stable at 6-month follow-up.

LESSONS

The orientation of the graft kidney has a significant influence on the location of the ureter. Upward orientation of the hilum will result in superficial location of the ureter, rendering it close to the hernial sac and susceptible to incarceration. The transplant surgeon should be aware of such a presentation of graft dysfunction with inguinal hernia to prevent a delay in the diagnosis and graft loss.

A rare case of herniated duplex collecting system causing obstructive uropathy

BACKGROUND

An inguinal hernia is the protrusion of intraabdominal organs through an opening in the abdominal wall. Structures such as small and large intestines are commonly contained within inguinal hernias. However, uretero-inguinal hernia of the native collecting system is an extremely rarely reported entity. If unrecognized, acute kidney injury due to obstructive uropathy or serious intraprocedural ureteral injuries during hernia repair can occur. A duplex collecting system is a congenital kidney anomaly with an incidence of 0.8%. A uretero-inguinal hernia involving duplicated ureters has not been previously described in literature. Here we report a case of obstructive uropathy secondary to uretero-inguinal hernia involving duplicated ureters.

CASE PRESENTATION

A 78-year-old male known to have a left sided inguinal hernia presented to the Emergency department with two weeks of intermittent suprapubic tenderness, dysuria, frequency, urgency, frothy urine as well as nausea and vomiting. Workup on admission revealed an elevated creatinine of 2.8 mg/dl. CT imaging revealed duplicated left sided ureters with left inguinal hernia containing the ureters. There was cystic ureteral dilation within the herniation sac as well as moderate left hydroureteronephrosis. Patient had an elective inguinal hernia repair with left ureteral stent placement. Following the surgery, he had recovery of kidney function to the previous baseline serum creatinine of 1.5 mg/dl.

CONCLUSION

A duplex collecting system arises when two ureteral buds are formed during fetal development. However, diagnosis can be made in rare instances during adulthood when duplex collecting systems are usually found incidentally. Uretero-inguinal hernias have been reported as a common complication of renal transplant. However, uretero-inguinal hernias in native kidneys are considered an uncommon finding, especially with a duplex collecting system. When patients present with herniation and acute kidney injury, it is important to rule out the possibility of uretero-inguinal hernia to minimize complications such as obstructive uropathy and kidney failure. CT scan providing cross-sectional imaging is the ideal modality for identification of the site and etiology of urinary tract obstruction and site of herniation. If during imaging, an obstructive uropathy is observed, a nephroureteral stent or nephrostomy tube can be inserted to protect the ureter as well as relieve the obstruction, respectively.

Inguinal Herniation Containing Bladder, Causing Contralateral Allograft Hydroureteronephrosis-A Case Report and Literature Review

We report the first documented case of an inguinal hernia containing bladder, resulting in contralateral allograft hydroureteronephrosis. A 39-year-old male patient presented with allograft dysfunction, a contralateral inguinoscrotal hernia, and marked hydroureteronephrosis on ultrasound (US). Percutaneous nephrostogram and a retrograde cystogram suggested bladder herniation with incorporation of the contralateral ureteroneocystostomy into the hernia. Paraperitoneal bladder herniation was confirmed at surgery and hernioplasty was performed. Six-week follow-up revealed normal renal function with no sign of hernia recurrence. Despite occurring rarely, transplant ureter or bladder herniation should be considered in the differential diagnosis of hydroureteronephrosis. This case illustrates that the contralateral position of hernia to allograft does not necessarily preclude the hernia as the source of ureteric obstruction.

Magnetic resonance urography and laparoscopy in paediatric urology: a case series

Paediatric urology often presents challenging scenarios. Magnetic resonance urography (MRU) and laparoscopy are increasingly used. We retrospectively studied children affected by a disease of the upper urinary tract who after MRU were elected for laparoscopic treatment. This pictorial essay draws on our experience; it illustrates some specific MRU findings and highlights the usefulness of MRU for the diagnosis of upper urinary tract pathology in children. It also offers some examples of the potential additional diagnostic information provided by laparoscopy as well as its therapeutic role.

Complications of renal transplantation

Continued improvements in graft survival have led to widespread acceptance of renal transplantation as the preferred treatment for the majority of patients with end-stage renal disease. The long-term care of these patients is often provided away from transplantation centers. This article presents both the clinical and imaging features of renal transplantation complications and their interventional management. Urologic and vascular complications may occur. Vascular complications include renal artery stenosis and renal artery and renal vein thrombosis. Ultrasound can accurately depict and characterize many of the potential complications of renal transplantation and increasingly magnetic resonance imaging also facilitates this role. In addition, interventional radiologic techniques allow nonsurgical treatment.

Obstructive uropathy secondary to ureteral herniation in a pediatric en bloc renal graft

Ureteral herniation is a rare entity. We report the first case of extraperitoneal ureteral herniation in a pediatric en bloc renal graft causing obstructive uropathy. A 70-year-old, obese patient with an en bloc renal transplant was found to have ureterohydronephrosis in the right renal graft on magnetic resonance imaging. Nephrostomy with insertion of a double-J catheter confirmed the presence of a ureteral loop within the inguinal tract. Surgery confirmed herniation of the ureter through the internal inguinal ring, crossing over the spermatic cord. We performed release, resection, ureteral reimplantation and hernioplasty. Four months later, renal function was normal and urinary tract dilation had diminished. This case illustrates an unusual cause of obstructive uropathy in a transplanted kidney. Apart from obesity, two other factors may have contributed to its development: presence of a redundant ureter, and the fact that the ureter had been placed over, rather than under, the spermatic cord.