Inguinoscrotal herniation of the ureter: Description of five cases

Abstract

INTRODUCTIONDescent of the ureter into the inguinal canal or scrotum is rare but undoubtedly underreported. Most known cases were recognized at the time of surgery for hernia repair. We encountered five cases recently.PRESENTATION OF CASEWe reviewed the records and CT images of five patients with inguinal hernias containing a segment of the ureter. All of our cases, like most reported cases, featured obese adult males. Our cases had different outcomes, ranging from inadvertent injury of the displaced ureter to correction of the anomaly at the time of hernia repair.DISCUSSIONIn all of our cases, the affected ureter was displaced anteriorly from the psoas muscle by greater than 1 cm at the level of the L4 vertebra on abdominal CT. This association has not been previously described.CONCLUSIONPre-operative diagnosis by CT can prevent injury to the ureter. We hypothesize that anterior displacement of the ureter at the level of L4 as seen on CT may be predictive of inguinoscrotal herniation of the ureter.

A sign on CT that predicts a hazardous ureteral anomaly

“…In each of our five recent cases, abdominal CT revealed an abnormal location of the affected ureter in its mid-course [2] . Unlike the normal contralateral ureter, which coursed immediately anterior to the psoas muscle at the level of the L4 vertebra, the ureter with the abnormal pelvic course also had an abnormal position at the L4 level, lying in retroperitoneal fat markedly anterior to the psoas muscle.…”

“…Descent of the ureter into the inguinal canal or scrotum may occur with an inguinal hernia, but is quite rare. Our literature search suggests that approximately 64 cases have been reported [1] , although a recent case series of five patients suggests that the prevalence of this anomaly is underestimated [2] . While the “curlicue” sign of a looping ureter has been shown to be pathognomonic for ureteral herniation on X-ray urograms, it is not very sensitive [3] .…”

“…Anomalous descent of the distal ureter into the inguinal canal or scrotum is a rare condition, with approximately 64 cases reported in the English language literature [1] . A recent case series suggests that this is under-reported [2] . Many reported cases were noted at the time of surgical exploration, often for inguinal hernia repair, or later as a result of an operative injury.…”

Asymptomatic herniation of ureter in the routine inguinal hernia: A dangerous trap for general surgeons

“…Although ureteral hernias were first described in the late 18th century, there have only been <70 cases reported in the English language literature. [ 1 , 2 ] It more commonly occurs in either obese patients or in those who are post renal transplantation. Fewer than 10 cases have been reported of ureteral inguinal hernias in adults with native kidneys, with most being symptomatic and diagnosed preoperatively [ 3 ].…”

A rare diaphragmatic ureteral herniation case report: endoscopic and open reconstructive management

“…Ureteral herniations are a rare occurrence normally found incidentally on imaging or during surgical hernia correction and can be a cause of ureteral obstruction [1]. These herniations can occur in several locations including the inguinal, femoral, sciatic, obturator, and thoracic regions [2].…”