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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2014  |  Volume : 25  |  Issue : 1  |  Page : 153-155
Inguinal herniation of the bladder and ureter: An unusual cause of obstructive uropathy in a transplant kidney


1 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication7-Jan-2014
 

How to cite this article:
Vyas S, Chabra N, Singh SK, Khandelwal N. Inguinal herniation of the bladder and ureter: An unusual cause of obstructive uropathy in a transplant kidney. Saudi J Kidney Dis Transpl 2014;25:153-5

How to cite this URL:
Vyas S, Chabra N, Singh SK, Khandelwal N. Inguinal herniation of the bladder and ureter: An unusual cause of obstructive uropathy in a transplant kidney. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Nov 22];25:153-5. Available from: http://www.sjkdt.org/text.asp?2014/25/1/153/124549
To the Editor,

A 32-year-old male presented with acute renal failure. He had undergone a renal allograft transplant, placed in the tight iliac fossa, seven years earlier. The patient complained of shortness of breath and fatigue and noticed a decrease in the urine output. He also gave a history of incomplete emptying of the bladder and was practicing two-stage micturition (pa負ient empties normally located bladder, then voids again after manual compression of the hernia sac). Physical examination revealed an obese man with a large non-reducible right inguinal hernia. The serum creatinine was ele赳ated at 3.0 mg/dL. Sonography showed hydrouretronephrosis. Magnetic resonance (MR) urography [Figure 1] and [Figure 2] revealed hydrouretronephrosis; additionally, the distal transplant ureter along with part of the urinary bladder was trapped within the right inguinal hernia. The patient underwent herniorrhaphy for the inguinal hernia, following which the serum creatinine came down to 1.8 mg/dL after three months of post-operative follow-up.
Figure 1: T2W axial section of magnetic resonance imaging of the lower abdomen and inguinal and scrotal regions showing hydronephrotic transplant kidney (A), dilated ureter (arrow) close to the right deep inguinal ring (B) and urinary bladder and ureter (arrows) seen within the scrotal sac (C and D).

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Figure 2: T2W coronal section of magnetic resonance (MR) imaging of the lower abdomen (A) and 3D maximum intensity projection MR urography (B) showing hydronephrotic transplanted kidney with dilated ureter (arrows) and herniated transplant ureter and bladder (asterisk) into the right inguinoscrotal sac.

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Ureteral obstruction comprises almost half of the urologic complications after renal transplan負ation. Several causes have been implicated, including development of stricture, lymphocele, ischemia/fibrosis, stone, ureteral injury, uretero-pelvic junction obstruction and ureteral kinking. Herniation of the transplanted ureter is an extremely rare, but described, etiology of obstructive uropathy. Most cases of late ureteral obstruction after renal transplantation result from obstruction in the lower ureter or uretero-vesical junction or ischemia of the lower ureter. [1],[2] The factors that most likely contribute to inguinal herniation of the trans計lant ureter include the following: The uretero- neocystostomy is performed by placing the donor ureter over the spermatic cord, which may predispose to obstruction and, secondly, the patient in our case was obese, which might have caused laxity of the inguinal floor. Thirdly, the patient's ureteral length was excessive, allowing it to fall into the inguinal canal. [3] From the anatomical and pathological view計oints, there are two types of ureteral inguinal hernias: Para-peritoneal (more frequent) and extra-peritoneal (uncommon). The para-perito要eal type is accompanied by a herniated peri負oneal sac adjacent to the ureter. The extra-peritoneal type often presents with urinary symptoms and only the ureter herniates through the inguinal canal, without the pre貞ence of the peritoneal sac. [2] According to their relationship with the peritoneum, bladder her要ias have been classified into three types, including paraperitoneal, intraperitoneal and extraperitoneal hernias. Paraperitoneal hernias are the most frequent type, and the extra-peritoneal portion of the hernia lies along the medial wall of the sac. In intraperitoneal her要ias, the herniated bladder is completely co赳ered by the peritoneum whereas in extra-peritoneal hernias, the bladder herniates with觔ut any relationship with the peritoneum. Performing a nephrostomy and antegrade stenting may temporarily improve renal function and assist in temporary reduction of the herniated ureter. However, definitive operative herniorrhaphy must always be employed. Ureteral re-implantation may not be necessary even in cases with excess ureteral length. [4]

In conclusion, extraperitoneal ureteral herniation and incarceration of the transplant ureter into an inguinal hernia is a rare cause of obstructive uropathy. MR urography is a very useful modality for demonstrating the anatomy and relationship of herniated ureters and bladder.

 
   References Top

1.Sánchez AS, Tebar JC, Martín MS, et al. Obs負ructive uropathy secondary to ureteral herniation in a pediatric enbloc renal graft. Am J Transplant 2005;5:2074-7.  Back to cited text no. 1
    
2.Furtado CD, Sirlin C, Precht A, Casola G. Unusual cause of ureteral obstruction in trans計lant kidney. Abdom Imaging 2006;31:379-82.  Back to cited text no. 2
    
3.Ingber MS, Girdler BJ, Moy JF, Frikker MJ, Hollander JB. Inguinal herniation of a transplant ureter: Rare cause of obstructive uropathy. Urology 2007;70:1224.e1-3.  Back to cited text no. 3
    
4.Bhagat VJ, Gordon RL, Osorio RW, et al. Ureteral obstructions and leaks after renal transplantation: Outcome of percutaneous ante-grade ureteral stent placement in 44 patients. Radiology 1998;209:159-67.  Back to cited text no. 4
    

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Correspondence Address:
Sameer Vyas
Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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DOI: 10.4103/1319-2442.124549

PMID: 24434401

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