Different Management Options for Transplant Ureteral Obstructions within an Inguinal Hernia

Abstract

Ureteral obstruction secondary to an inguinal hernia with transplant ureteral component is an extremely rare entity with only several case reports found in literature. In all previously reported cases, management of the obstruction involved temporary drainage with ureteral stenting or nephrostomy tube placements followed by delayed definitive repair. We present two case reports, here one being the first one managed by immediate definitive repair via ureteral reimplant and herniorrhaphy and a second case by delayed definitive repair after percutaneous nephrostomy tube placement. Both patients continued to do well postoperatively with normalization of renal function on follow-up.

As in Real Estate, Location Is What Matters: A Case Report of Transplant Ureteral Obstruction Due to an Inguinal Hernia

“…It is important to note that inguinal herniation of a transplant ureter can be accompanied by bladder herniation contralateral to the allograft, 19-20 although this was not the case in our patient as his hernia was ipsilateral to the allograft. A review of previously published case reports suggests several risk factors for the development of inguinal herniation of the transplant ureter that were also present in our patient, including male sex, 1-20 age 50 years or greater, 1,3,5-7,9-12,14,15,17,19,20 and having had a kidney transplant for at least 5 years. 2-15,17-20 Other risk factors for inguinal herniation of a transplant ureter may include an excessive ureteral length, 3,12-14 placement of the donor ureter anterior to the spermatic cord, 3,13,14 and obesity, …”

“…Our case represents an uncommon cause of ureteral obstruction and acute kidney allograft dysfunction from inguinal herniation of a transplant ureter, with 21 reported cases in the literature. 1 - 20 This case highlights several learning points. Awareness of transplant ureteral obstruction is important because it is a cause of acute kidney allograft dysfunction that can easily be missed.…”

“…Management of transplant ureteral obstruction varies among institutions but can include ureteral stenting 1 , 3 , 6 , 8 , 9 , 10 - 12 , 19 to minimize allograft dysfunction and allow for its identification and isolation during inguinal hernia repair. Nephrostomy insertion may also be necessary for immediate decompression of the collecting system to prevent irreversible graft dysfunction, 1 - 4 , 6 , 8 - 12 , 15 , 17 , 19 , 20 while awaiting definite management with hernia repair but was not required in our patient as his creatinine declined following ureteral stent insertion and he underwent a timely hernia repair 5 days after the hernia was diagnosed. Although rare, the important takeaway message is that transplant ureteral obstruction be recognized in the differential diagnosis of hydronephrosis and acute kidney allograft dysfunction for prompt evaluation and the prevention of graft loss.…”

Contralateral inguinal herniation of a transplant ureter causing obstructive uropathy in a renal transplant recipient

“…Alternative management strategies include immediate repair of the ureteral obstruction with herniorraphy and ureteric re-implantation14 and conservative management with an antegrade stent in those unfit for surgery 11…”

Inguinal Herniation Containing Bladder, Causing Contralateral Allograft Hydroureteronephrosis—A Case Report and Literature Review

“…In six of 17 operative procedures, ureteric reimplantation was performed before hernia repair. Indications included ureteric redundancy , course ventral to spermatic cord , ureteric fibrosis, and ureteroneocystostomy stenosis . In four of these cases, the use of synthetic mesh were avoided .…”