Obstructive Uropathy Secondary to Ureteroinguinal Herniation

CASE REVIEW Obstructive Uropathy Secondary to Ureteroinguinal Herniation Karyn S. Eilber, MD,* Stephen J. Freedland, MD,† Jacob Rajfer, MD* *Division of Urology, Harbor-UCLA Medical Center, Los Angeles, CA Department of Urology, UCLA School of Medicine, Los Angeles, CA † Herniation of the ureter occurs infrequently in a sliding inguinal hernia. Massive herniation may cause ureteral obstruction leading to hydronephrosis. Computed tomography can demonstrate both ureteral herniation and associated hydronephrosis. [Rev Urol. 2001;3(4):207–208] © 2001 MedReviews, LLC Key words: Ureter • Hernia • Obstruction A 72-year-old man with a recent myocardial infarction presented with a gradually enlarging scrotum. The patient denied any previous history of herniorrhaphy, abdominal or scrotal pain, or obstructive voiding symptoms. Physical Examination Physical examination revealed bilateral, massive, nontransilluminating scrotal enlargement, which was not reducible. The serum blood urea nitrogen was 37 mg/dL (normal 10 to 20 mg/dL) and serum creatinine was 1.7 mg/dL (normal 0.5 to 1.2 mg/dL). A scrotal ultrasound revealed normal testes and large bilateral inguinal hernias. Computed tomography (CT) of the abdomen and pelvis also confirmed the presence of massive bilateral inguinal hernias involving the right ureter and bladder (Figure 1A) and right hydroureteronephrosis with cortical thinning and a normal-appearing left kidney (Figure 1B). The right kidney contributed only 10% of total renal function, as indicated by MAG-3 nuclear scanning. After consideration of the patient’s cardiac disease, lack of symptoms, and low likelihood of strangulation with such massive herniation, herniorrhaphy was not performed. It was determined that reduction of such massive hernias VOL. 3 NO. 4 2001 REVIEWS IN UROLOGY 207 Ureteroinguinal Herniation continued A B Figure 1. (A) Computerized tomography reveals scrotal herniation of bladder and ureter (arrow). (B) Severe right hydronephrosis with cortical thinning (arrow). would pose a high risk of respiratory and cardiac compromise. Discussion While the presence of bladder association with an inguinal hernia is reported to occur in approximately 1% to 4% of all adult hernias, herniation of the ureter is rare.1 Leroux first reported ureteral herniation in 1880 as an autopsy finding.2 Since then there have been just over 100 reported cases.3,4,5 When present, ureteral herniation is associated with inguinal hernias twice as often as with femoral hernias.5 Both men and women are affected, with inguinal hernias predominating in male patients and femoral hernias in female patients.5 Due to the invariably large size of the hernia, incarceration and strangulation are infrequent.1 Urologic symptoms indicating bladder outlet obstruction may occur in the presence of associated bladder herniation, including frequency, nocturia, dysuria, and hematuria.3 Urinary anomalies are common in these patients, so imaging of the urinary tract is warranted when a ureteral hernia is incidentally discovered.1,6 Classification of ureteral hernias is based on the presence or absence of a concomitant hernia sac.1,3 The most common variety of ureteroinguinal hernia is the paraperitoneal type and is associated with a hernia sac, while the extraperitoneal type is not. The paraperitoneal type is actually a sliding hernia with the ureter constituting part of the hernia sac wall.5 Extraperitoneal ureteroinguinal herniation is the least common form and involves herniation of the ureter alone without an associated peritoneal sac. Both the paraperitoneal and extraperitoneal hernias are predominantly indirect.5 Preoperative diagnosis of ureteral herniation is helpful to avoid inadvertent injury; however, most cases have been diagnosed at the time of operation or postoperatively because of urinary leakage from the wound.2,3 With the increasing use of CT, ureteroinguinal hernias and associated anomalies may be more commonly diagnosed by this modality. Assuming no contraindication to surgery, herniorrhaphy is indicated to prevent obstructive uropathy. At the time of herniorrhaphy it is necessary to carefully dissect the ureter free. Simple reduction may be performed if the herniated ureteral segment appears viable. Any diseased or significantly dilated areas require excision with primary anastamosis.2 Conclusion Ureteroinguinal herniation is an uncommon phenomenon and is usually discovered at the time of herniorrhaphy. When an ureteroinguinal hernia is present, the upper urinary tract should be evaluated for any associated anomalies. The diagnosis of ureteroinguinal herniation may be facilitated by computed tomography. References 1. 2. 3. 4. 5. 6. Pasquale MD, Shabahang M, Evans SRT. Obstructive uropathy secondary to massive inguinoscrotal bladder herniation. J Urol. 1993;150:1906-1908. Mallouh C, Pellman CM. Scrotal herniation of the ureter. J Urol. 1971;106:38-41. Watson LR. Hernia: Anatomy, Etiology, Symptoms, Diagnosis, Differential Diagnosis, Prognosis and Treatment. 3rd ed. St. Louis: Mosby; 1948. Ballard JL, Dobbs RM, Malone JM. Ureteroinguinal hernia: A rare companion of sliding inguinal hernias. Am Surg. 1991;57:720-722. Pollack HM, Popky GL, Blumberg ML. Hernias of the ureter-An anatomic-roentgenographic study. Radiology. 1975;117:275-281. Dourmashkin RL. Scrotal hernia of the ureter associated with unilateral fused kidney; case report. J Urol. 1937;38:455-467. Main Points • Since the condition was first described in 1880, there have been just over 100 reported cases of ureteral herniation. • Inguinal hernias predominate in male patients and femoral hernias in female patients. • The paraperitoneal type of ureteroinguinal hernia is associated with a hernia sac. • Extraperitoneal ureteroinguinal herniation is the least common form and involves herniation of the ureter alone without an associated peritoneal sac. • Herniorrhaphy is indicated to prevent obstructive uropathy. 208 VOL. 3 NO. 4 2001 REVIEWS IN UROLOGY