Obstructive uropathy in the context of ureteroinguinal hernia: experience of challenges in surgical management of an unwell patient

Background

Ureteroinguinal hernias are rare, with roughly 170 cases having been reported worldwide since 1970, with the majority of these cases having been documented in renal transplant recipients. The number of ureteroinguinal hernias reported in patients with native kidneys may be as low as 10 worldwide, making this case an extremely rare anatomical occurrence.1

Here we report a case of a 130 cm ureter which has herniated through the superficial inguinal ring into the right hemiscrotum before returning to the pelvis without incarceration. This patient was concurrently affected by an obstructing 12 mm vesicoureteric junction (VUJ) calculus causing urosepsis. Due to the rarity of this anatomical variation, conventional surgical methods were not suitable for management.

This case highlights the importance of a stepwise approach to complicated presentations and the need for careful surgical planning preoperatively. Similarly, a high index of suspicion must be given to patients presenting with obstructive uropathy and known history of inguinal hernia to help reduce iatrogenic damage intraoperatively and the associated long-term complications.

Case presentation

A 72-year-old comorbid man was transferred overnight to a tertiary centre with septic shock thought secondary to urosepsis in the context of an obstructing right-sided 12 mm VUJ calculus. Complicating this presentation was an acute exacerbation of chronic obstructive pulmonary disease (COPD) requiring high-flow nasal prongs at 40 L/40% FiO₂ to maintain adequate oxygen saturation.

This is on a background of known COPD with a 35-pack-year smoking history, chronic kidney disease with a baseline creatinine of 260, hypertension and a hypotonic bladder with associated long-term Indwelling Catheter (IDC). Of note, the patient was not previously known to any previous surgical procedures.

A physical examination revealed a hypotensive patient with blood pressure of 90/58 mm Hg, a heart rate of 110 beats/min and a temperature of 38.7°C. Examination of the chest revealed bilateral wheeze consistent with an exacerbation of COPD.

Investigations

Blood results revealed raised inflammatory markers as well as an acute chronic kidney injury with a serum creatinine of 630 with normokalaemia from a baseline of 260. The CT performed pretransfer revealed a grossly dilated and tortuous ureter with an obstruction of the distal right ureter secondary to a 12 mm VUJ calculi (figures 1 and 2). The proximal right ureter was noted to herniate through the superficial inguinal ring into the right hemiscrotum before returning to the pelvis without incarceration (figure 3). This was not present on previous CT scan performed 4 years previously. The urine cultures grew Pseudomonas aeruginosa; therefore, appropriate antibiotics were commenced.

Treatment

Treatment of infected/obstructed kidneys can be achieved by either percutaneous nephrostomy insertion or cystoscopic placement of a ureteric stent. However, with this patient’s worsening respiratory function, the decision was made that a nephrostomy under local anaesthetic would be more appropriate. A 8.5 Fr percutaneous nephrostomy tube was inserted by interventional radiology and drained turbid urine, which was further cultured.

Ongoing respiratory management was required in the intensive care unit. The patient’s renal function significantly improved postnephrostomy and allowed ongoing medical optimisation and complex surgical planning.

Once the patient was clinically stable and the serum creatinine was down-trending, an anterograde stent through the nephrostomy tube was attempted by the interventional radiology team. Intraoperatively, the ureter was measured to be approximately 130 cm long. With such length and tortuosity of the ureter, no ureteric stents were able to be placed (figure 4).

This patient’s case and relevant images were reviewed at the renal stone multidisciplinary team (MDT) meeting to formulate a surgical plan for a ureter too long for standard equipment. As the calculi was low at the VUJ, the aim was for ureteroscopy with laser lithotripsy. If the calculi were to move intraoperatively retrograde up to the renal pelvis, the MDT agreed the best plan would be conservative management as the patient was not deemed fit enough for percutaneous nephrolithotomy.

Under a spinal anaesthesia, cystoscopy showed a bulging VUJ with vision of the calculi. A combination of VUJ incision and laser lithotripsy cleared the ureter and the incidental bladder calculus. A covering ureteric catheter was left in place to the mid-ureter, attached to the urinary catheter for 4 days to aid decompression.

Outcome and follow-up

The patient’s renal function returned to baseline and there were no postoperative complications. He was referred to the general surgeons for consideration of a right sided ureteroinguinal hernia repair. Due to the gross dilatation and anatomical distortion of the obstructed ureter, the risks associated with acute hernia repair were significant. Open surgical repair was to be considered in an outpatient setting once the patient had recovered from his active medical issues and the hydroureter had resolved. The patient was discharged back to a peripheral hospital for ongoing respiratory input and medical optimisation of his comorbidities.

The patient is due to be followed up by urology in an outpatient setting with a repeat non-contrast CT to elucidate residual stone burden.