Difficulties in Diagnosing Extraperitoneal Ureteroinguinal Hernias: A Review of the Literature and Clinical Experience of a Rare Encounter in Acute Surgical Care Settings

Abstract

Although inguinal hernia repair is one of the most common surgical procedures, finding a retroperitoneal structure, such as the ureter, is a rather rare occurrence. Ureteroinguinal hernias may arise in the presence or absence of obstructive uropathy, the latter raising difficulties in diagnosis for the general surgeon performing a regular inguinal hernia surgery. This study aims to collect the relevant literature describing the diagnosis and management of ureteroinguinal hernias and update it with a case encountered in our clinic. The following study was reported following the SCARE guidelines. The relevant literature describes less than 150 cases of ureteroinguinal hernias overall, considering the 1.7% prevalence of inguinal hernias in the general population. With only 20% of these hernias being described as extraperitoneal, such an encounter becomes an extremely rare finding. Our clinical experience brings a case of a 75-year-old male with frequent urinary tract infections and a large irreducible inguinoscrotal hernia of about 20/12 cm located at the right scrotum. The patient underwent an open inguinal hernia repair technique under general anesthesia, incidentally finding an extraperitoneal ureteral herniation. Segmental ureterectomy was performed with uneventful recovery. Intraoperatively, finding an incidental ureteroinguinal hernia raises concerns about probable urinary tract complications during regular hernia repair surgery and whether the diagnosis is likely to happen prior to surgical intervention. Although imaging is rarely indicated in inguinal hernias, the case reports show that a pelvic CT scan with urography in symptomatic patients with urinary symptoms will provide accurate confirmation of the diagnosis. The relevant literature is limited due to the rarity of respective cases, thus making standardized management of such cases unlikely.

Ureteroinguinal herniation complicated by obstructive uropathy and pyelonephritis

“…The first autopsy report of an inguinal ureteric herniation dates back to 1880, and the diagnosis was rarely made pre-operatively until the 21st century [1] . Approximately 140 cases have been reported in the literature, many of these occurring following renal transplant [3] , [4] , [5] – 6] . Native ureteric herniation appears to be rarer still.…”

“…While there are prior reports of obstructive uropathy due to ureteric compression in the inguinal canal [3 , 10 – 12] , it has to date been assumed that ureteric strangulation and obstruction is rare [7] . When obstruction does occur, it can be assumed that there will be an increased risk of superimposed pyelonephritis, as with other causes of obstructive uropathy [13] .…”