Inguinal herniation of a transplant ureter: rare cause of obstructive uropathy

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.     

An unusual cause of back pain in an achondroplastic man

A case is described of a 47-year-old man with achondroplasia who presented with lower back pain radiating to his left loin. An intravenous urogram (IVU) showed hydronephrosis on the left side and a dilated left ureter passing down into the left inguinal region. A CT scan confirmed a left inguinal hernia containing the left ureter causing ureteric obstruction. The hernia was repaired using the Lichtenstein technique with the ureter replaced retroperitoneally. A postoperative IVU showed recovery in renal function but with a persistently dilated left ureter that was not obstructed. A review of the literature regarding inguinal herniation involving the ureter is presented.     

Femoral herniation of transplanted ureter after deceased-donor kidney transplantation

IntroductionHerniation of the ureter after kidney transplant is a rare and under documented event. Many of these herniations are due to abdominal wall defects or ureteral redundancy. After an extensive review of available literature, there has not been a reported case of a femoral herniation of ureter after kidney transplant. We report a case of late allograft renal transplant failure due to ureteral obstruction secondary to femoral herniation of the ureter.Case presentationWe report a case of 64 year old male with a history of kidney transplant, who was found to have an inguinal bulge. He was diagnosed with a femoral hernia containing transplant ureter using transplant kidney ultrasound and CT of the abdomen and pelvis. Subsequently he developed transplant kidney failure due to obstructive uropathy from the femoral hernia. The patient underwent a femoral hernia repair with biologic mesh. Compromised ureter was excised and a neoureterocystostomy was created. Post operatively his creatinine returned to baseline.DiscussionIn our literature search there are two types of inguinal ureteral hernias described. Paraperitoneal, which makes up the majority of the cases, and extraperitoneal. There are no classifications for ureteral femoral hernias. We may extract these definitions to femoral hernias, as evidenced by our case where we encountered a paraperitoneal femoral hernia containing transplant kidney ureter.ConclusionTo the best of our knowledge this is the first reported case of a femoral ureter hernia. Due to its rarity in the literature, an understanding of management is critical to patient outcome.     

Intrascrotal hernia of the ureter and fatty hernia

Intrascrotal hernia of the ureter is a rare event. We describe here one such case. There are two anatomic types of such ureteral hernias. The paraperitoneal type has a peritoneal indirect sac, which pulls the ureter with it. The extraperitoneal ureteral hernia is without a peritoneal sac. In such cases, which are almost always indirect hernias, there is usually a large amount of fat. It is, in fact, retroperitoneal fat, which slides, and pulls the ureter with it by gravity. Such a case is a genuine prolapse of the retroperitoneal structures. This anomaly, which has been rarely studied, is worth knowing about, because the ureter may be damaged during hernia dissection. The surgeon should be cautious when discovering huge fatty hernias, and should avoid the excision of fat and simply return the fatty mass to its normal place after its separation from the cord. Electronic Publication     

A case of ureteral polyp in childhood

A case of ureteral polyp in a 7-year-old boy with the chief complaint of left flank pain was reported. The excretory urogram and retrograde pyelography showed left hydronephrosis and a filling defect at the pelvic-ureteric junction. Partial resection of the ureter containing the lesion and Anderson-Hynes pyeloplasty were performed. The pathological diagnosis was benign polyp of the ureter. Convalescence was uneventful and excretory urogram showed improvement of the hydronephrosis. Along with our case, 19 cases of ureteral polyp in childhood are briefly discussed.     

Unilateral hydronephrosis with hypertension due to ureteral endometriosis

A 35-year-old female patient was hospitalized for a headache. She was referred to our department for the evaluation of right hydronephrosis noted on the excretory urogram which was performed as part of a hypertensive diagnostic study. Endocrine examination revealed renal hypertension. Excretory urogram and antegrade pyelography showed obstruction of the lower part of the right ureter. On surgical exploration, the lower part of the right ureter was surrounded by brown tissue. Complete hysterectomy and ureterovesiconeostomy were performed. Histologically, the brown tissue around the ureter was diagnosed as endometriosis. One year after the operation, excretory urogram showed normal urinary tract and the blood pressure was 130/80 mmHg. Endometriosis is a common gynecological disease but ureteral endometriosis is relatively rare. Review of the Japanese literature disclosed 16 previous cases of ureteral endometriosis and we report the 17th case with a review of the literature.     

Ureteral polyp: a difficult case to make a differential diagnosis with ureteral tumor]

We report a case of primary fibroepithelial polyp of the left ureter. The patient was a 34-year-old-man, complaining of left flank pain. An excretory urogram and retrograde pyelogram revealed left hydronephrosis and filling defect of the middle third of ureter. It was difficult to make a differential diagnosis with ureteral tumor. A frozen section revealed no malignancy and we performed partial ureterectomy and end-to-end anastomosis. We discussed the clinical features of adult primary ureteral polyp reported in the Japanese literature.     

A case of ureteral polyp in a young man with renal autotransplantation

We report a case of fibroepithelial polyps of the ureter in a 18-year-old boy with the chief complaint of left flank pain. An excretory urogram and retrograde pyelogram revealed left hydronephrosis and a filling defect at the pelvic-ureteral junction. This ureteral disorder was corrected by the renal autotransplantation for conserving the renal function. The pathological diagnosis was fibroepithelial polyps of the ureter. Convalescence was uneventful and after 3 months of follow up, excretory urogram and 99mTc-DTPA renogram showed good renal function and improvement of hydronephrosis. Along with our case, we briefly reviewed 32 cases of ureteral polyp in men under 20 years old.     

Inguino-scrotal hernia of a double district ureter: case report and literature review

Ureteral hernia is uncommon and usually misdiagnosed. From an anatomic point of view, we can distinguish between two uretero-inguinal hernias: intraperitoneal and extraperitoneal. Ureter inguinal hernias are nearly always indirect. This kind of hernia can include the ureter alone or, frequently, other abdominal sliding organs within the hernia sac (bladder, bowel tracts, etc.). Kidneys and urinary tracts present normal anatomic conformation, although renal ptosis may be found. As of July 2004, 139 cases of ureteral hernia had been described in the literature. Here we report a case of inguino-scrotal herniation of double district ureter and review the current literature to analyze the main clinical characteristics of this pathology and to establish pitfalls.     

Inguino-scrotal herniation of the ureter containing stones

Background

Inguino-scrotal herniation of the ureter is a rare and difficult situation for a surgeon, especially if only recognized during inguinal hernia repair.

Methods

An 83-year-old gentleman, with a previous history of radiation treatment for squamous anal cancer, presented with a large left inguinoscrotal hernia causing occasional pain at the base of the scrotum. Follow-up, post-radiation therapy CT scan showed a hernia sac containing the bladder and large bowel. Calcifications in the sac were interpreted as bladder stones, in keeping with the history of left renal calculi.

Results

During hernia repair careful dissection revealed a herniated portion of the left ureter located alongside a large hernia sac, complicated by ureteral calculi. Following stones extraction and ureteral repair, hernia repair with mesh was successfully accomplished. Pathogenesis of ureteric herniation is reviewed.

Conclusion

A herniated ureter is potentially a source of serious renal or ureteral complications. When discovered, ureteric hernias should be surgically repaired. If preoperative detection of a ureter herniation alongside an inguinal hernia is missed, awareness of the existence of this condition may help avoid iatrogenic ureteral damage injury during a complex hernioplasty. Documentation of unexplained, sizeable and distinct calcifications in an inguino-scrotal hernia sac, particularly in a patient with a history of urolithiasis, may suggest the presence of a herniated, calculus-filled ureter. In such cases, retrograde pyelograms may be considered for a definitive diagnosis prior to surgery.

     

Ureteral obstruction and pyelonephritis caused by an inguinal hernia: report of a case.

An elderly man had pyelonephritis and sepsis owing to ureteral obstruction. Retrograde pyelography showed entrapment of the right ureter in an inguinal hernia. This condition, which may be congenital or acquired, should be considered before herniorrhapy is performed and as a possible cause of ureteral obstruction.     

A sign on CT that predicts a hazardous ureteral anomaly

IntroductionAn aberrant course of the distal ureter can pose a risk of ureteral injury during surgery for inguinal hernia repair and other groin operations. In a recent case series of inguinoscrotal hernation of the ureter, we found that each affected ureter was markedly anterior to the psoas muscle at its mid-point on abdominal CT. We hypothesized that this abnormality in the abdominal course of the ureter would predict the potentially hazardous aberrant course of the distal ureter.Presentation of casesWe reviewed all evaluable CT urograms performed at St. Louis University Hospital from June 2012 to July 2013 and measured the ureteral course at several anatomically fixed points.Discussion93% (50/54) of ureters deviated by less than 1 cm from the psoas muscle in their mid-course (at the level of the L4 vertebra). Reasons for anterior deviation of the ureter in this study included morbid obesity with prominent retroperitoneal fat, congenital renal abnormality, and post-traumatic renal/retroperitoneal hematoma. We determined that the optimal level on abdominal CT to detect the displaced ureter was the mid-body of the L4 vertebra.ConclusionAnterior deviation of the ureter in its mid-course appears to predict inguinoscrotal herniation of the ureter. This finding is a sensitive predictor and should raise concern for this anomaly in the appropriate clinical setting. It is not entirely specific as morbid obesity and congenital anomalies may result in a similar imaging appearance. We believe that this association has not been reported previously. Awareness of this anomaly can have significant operative implications.     

A case of primary ureteral carcinoma in the duplicated renal pelvis and ureter diagnosed by transurethral uretero-renoscopy

We present a case of primary ureteral carcinoma in the duplicated renal pelvis and ureter diagnosed by transurethral uretero-renoscopy. The case was of a 78-year-old man with the complaint of sudden asymptomatic macrohematuria. An excretory urogram strongly suggested the presence of duplication of the right collecting system, and cystoscopy revealed a gross hematuria from the right ureteral orifice. A retrograde ureteropyelogram revealed incomplete duplication of the right renal pelvis and ureter fused at about the ureter crossing over the iliac vessels, and a polyp-like filling defect in the lower segment of duplicated ureter at about 4 cm from the fusion of the ureters. Transurethral uretero-renoscopy was employed to investigate the filling defect, and a papillary tumor extended into the lower segment of duplicated ureter was revealed. Tumor was resected by a rigid operating instrument under transurethral uretero-renoscopy. The pathological diagnosis was grade I-transitional cell carcinoma of the ureter, so that right total nephroureterectomy with partial cystectomy was carried out subsequently. Surgical specimen after right total nephroureterectomy with partial cystectomy showed no other tumor in the pelvis or ureter macroscopically, and histopathological studies of surgical specimens were no evidence of malignancy. We believe that transurethral uretero-renoscopy significantly increases the diagnostic accuracy in determining the nature of upper urinary tract lesions, and this procedure is indispensable in the diagnosis of ureteral tumors. The present case was the 7th case of primary ureteral carcinoma in the duplicated renal pelvis and ureter in the Japanese literature.     

Urological findings in inguinal hernias: A case report and review of the literature

We report on a rare case of massive incarcerated inguinoscrotal bladder herniation in a direct hernia and present the review of the literature on urological findings in relation to the inguinal hernial sac. The English-based literature was searched using the words inguinal hernia, bladder, ureter, diverticule, and incarceration and discussed in relation to the present case. We found 190 cases of inguinal hernia associated with urological findings, such as herniation of the bladder, ureter, and diverticulum. We also found that 11.2% of these hernias were associated with urological malignancies and 23.5% of these were associated with a variety of complications. The high-risk patients, who are males, obese, older than 50 years and who have symptoms that indicate urological pathologies to a physician, are more likely to be in the high-risk group for bladder herniation.     

腹腔镜治疗腹股沟疝临床疗效、胃肠动力和应激水平变化分析

目的探讨腹腔镜完全腹膜外疝修补术（laparoscopic totally extraperitoneal,TEP）治疗成人腹股沟疝患者临床疗效、胃肠动力和应激水平变化。 方法回顾性分析2012年1月至2017年6月,徐州市中医院普外科收治的成人腹股沟疝患者60例,随机数字表法分为试验组和对照组,每组患者30例,试验组给予TEP治疗,对照组给予开放式改良Kugel手术治疗,观察2组患者治疗后疗效、疼痛程度、并发症发生率、胃肠动力和应激水平变化。 结果试验组治疗后有效率（93.33%）高于对照组（63.33%）,VAS疼痛评分（3.21±0.96）和并发症发生率（16.67%）低于对照组（5.68±1.17,46.67%）,血清GAS、MTL、InS和GH水平均明显高于对照组,而血清β-EP、BS水平均明显低于对照组,差异均有统计学意义（P均<0.05）。 结论TEP治疗成人腹股沟疝患者具有良好的临床疗效,可有效改善患者胃肠动力和应激水平。     

Two cases of ureteral endometriosis

We report two successfully treated cases of ureteral endometriosis. Case 1 is in a 47-year-old female who had a past history of simple hysterectomy and right oophorectomy. Pathological diagnosis was myoma uteri and pelvic endometriosis. Two months later, she visited our clinic for right flank pain. Excretory urogram and retrograde pyelogram revealed right hydroureteronephrosis and stricture of the right lower ureter. The diagnosis of ureteral endometriosis was made from the past history and clinical features. Danazol therapy started with a daily dose of 400 mg. Sixteen days later, excretory urogram demonstrated complete resolution of the right hydronephrosis. An intravenous pyelography about 1 year after the danazol therapy has indicated no recurrence. Case 2 is in a 35-year-old female who visited our clinic for right lumbar pain. Excretory urogram and retrograde pyelogram revealed right hydroureteronephrosis and stricture of the right lower ureter. Right ureterocystoneostomy was performed unsuccessfully resulting in endoscopic dilation. Right lower ureter was buried in the dense fibrous tissue approximately 5 cm below the crossing with iliac vessels. The area of obstruction was removed. Histologically, endometriosis was diagnosed. Twenty nine cases of ureteral endometriosis including our two cases were collected from the Japanese literatures and reviewed with respect to the clinical features and treatment.     

Spontaneous rupture of ureter

A patient with spontaneous ureteral rupture in the absence of obstruction or calculus disease is presented. In addition to ureteral rupture this patient also had a penile squamous cell carcinoma and infected inguinal lymph nodes. A review of the literature discloses that all reported cases with spontaneous rupture of the ureter had an underlying process leading to that rupture. It is considered, therefore, that rupture of the ureter should be designated as "traumatic" or "nontraumatic." The term "spontaneous," implying a primary event, is a misnomer. No such case has been reported occurring in an otherwise healthy individual.     

Primary carcinoma in situ of the ureter: a case report

A case of primary carcinoma in situ of the ureter in a 77-year-old man is reported. The patient had been to another hospital with right flank pain and macroscopic hematuria. Ultrasound sonogram showed right hydronephrosis. An excretory urogram showed right hydronephrosis and stenosis of right ureter. He was referred to our hospital for further evaluation and treatment. Retrograde pyelogram demonstrated a right ureteral stricture at the level of S1-2, but no space occupying lesion was detected in the ureter. Cytology of voided urine was negative for malignant cells and no other abnormal findings were present. Probe laparotomy was performed under the preoperative diagnosis of ureteral stricture. During the operation, frozen section examination of the stenotic ureter showed carcinoma in situ and so we performed right total nephroureterectomy with a bladder cuff. Pathologic diagnosis was primary carcinoma in situ of the right ureter. The patient has been doing well for six months postoperatively with no evidence of recurrent or metastatic disease.     

Mesh plug and ureteral necrosis after kidney transplantation

CASE REPORT: We present a 59-year-old male who underwent living related kidney transplantation. During the procedure a previously placed mesh plug was found to be adherent to structures in the vicinity of the area of implantation. After revascularization, neocystouretostomy was performed with the ureter over the spermatic cord in order to avoid excessive dissection through this adherent mass. Shortly thereafter the patient was diagnosed with a ureteral leak and returned to the operating room. The intraoperative findings included adhesion of the ureter to the mesh plug with necrosis of its distal portion. A redo neocystouretostomy was performed. The patient recovered uneventfully. CONCLUSION: This case report illustrates a unique cause of a urinary fistula related to mesh plug open inguinal hernia repair and demonstrates the importance of ensuring a safe distance between vital structures and any prosthetic device.     

Benign ureteral polyps in a child

A case of benign ureteral polyps at ureteropelvic junction in a 9-year-old boy is reported. He was hospitalized with episodes of gross hematuria and left flank pain. An excretory urogram showed the left hydronephrosis due to the ureteropelvic junction obstruction. At exploration, we found two polyps at the left ureteropelvic junction. Partial ureterectomy including the polyps and pyeloplasty were performed. Pathological examination showed fibrovascular polyps of the ureter. The patient still remains symptomless for one year after the operation with no signs of recurrent ureteral polyps.