A Rare Case of Obstructive Uropathy in Renal Transplantation: Ipsilateral Indirect Inguinal Herniation of a Transplant Ureter (2009)

Urologic complications after renal transplantation occur in 10% of cases; (1–7) 50% cases are obstructive (8–13). Inguinal herniation of the transplanted ureter is an extremely rare event (14–17). We review the literature and report a case of obstructive uropathy in a renal transplant recipient caused by herniation of the transplant ureter into the inguinal canal. Case Presentation A 76-year-old man with end-stage renal disease secondary to membranous nephropathy had a successful renal transplant 20 years ago. He presented with vague abdominal pain and a right inguinal hernia. His baseline creatinine increased from 50 to 110 μmol/L. Abdominal ultrasound and CT scan demonstrated a moderate hydroureteronephrosis with right-sided inguinal hernia containing a loop of ureter (Fig. 1a). An urgent percutaneous nephrostomy tube confirmed the presence of stenosis (Fig. 1b). Subsequently, he had angiographic balloon dilatation followed by an antegrade ureteral stent placement; this reduced the ureter out of the hernia sac. The patient’s creatinine dropped to 65 μmol/L. Repair of the hernia was performed electively, and the stent was removed 2 months later with no impact on renal function with a 1 year follow-up.FIGURE 1.: (a) Computed-tomography of the abdomen shows moderate hydronephrosis of the transplant kidney with extension of the ureter into an inguinal hernia. (b) Percutaneous nephrostogram shows moderate hydronephrosis and distal stenosis of the ureter. (c) The ureter was catheterized with a 0.018 in. wire, angioplasty of the stenotic area with a 6 mm balloon was performed and a new nephrostogram shows the JJ catheter in good position.Significant morbidity can result from posttransplant urologic complications (2). Most cases of late ureteral obstruction posttransplantation result from obstruction in the lower ureter or ureterovesical junction (1, 4, 18, 19) and are secondary to technical factors or ischemia (9–13). Although native ureteral and bladder herniation in an inguinal hernia have been previously described (20, 21), only a few cases of transplant ureteral herniation are reported: one in the obturator canal occurring in a woman (22) and four inguinal (14–17). Of these four inguinal ureteral herniations, all occurred in men and three were older than 70 years of age, as in our case. This reflects the increased preponderance of inguinal hernias in men and the increased prevalence with age. In all cases, the diagnosis was made by imaging studies. In addition to the general risk factors for inguinal herniation, the following two factors may have contributed to this case: (i) stricture at the uretrovesical junction, which may have led to tortuosity and kinking of the ureter into the existing inguinal hernia, and (ii) the existence of a redundant long ureter. Other reported factors include placement of the donor ureter over the spermatic cord (15) or accidental ligation of the ureter at the time of an elective hernia repair (1). The definitive treatment is operative herniorrhaphy usually without the need for ureteral re-implantation (14–17, 22). In a report of inguinal herniation from a pediatric en bloc donor, transection and re-implantation of an extremely redundant ureter was necessary (15). However, similar to our case, the surgeons for the remaining reported cases did not manipulate the ureter owing to its tenuous vascularization and healing potential, as transection or re-anastomosis may predispose to ureteric strictures or leaks. Before elective repair, immediate attention to the herniated ureter is important. By the use of interventional radiology, we demonstrate the early reversal of obstructive uropathy until the patient underwent elective hernia repair. The stented ureter may also be protected from damage during the hernia repair. Raed Azhar Marylise Boutros Mazen Hassanain Gerry Polyhronopoulos Prosanto Chaudhury Jean Tchervenkov Department of Surgery, Hepatopancreatobiliary and Solid organ Transplantation McGill University Health Centre, Montreal QC, Canada Tatiana Cabrera Department of Radiology McGill University Health Centre, Montreal QC, Canada