Obstructive uropathy caused by an inguinal hernia in a kidney transplant recipient: Report of hernia cure by the shouldice technique

Abstract

We report the case of kidney graft dysfunction secondary to ureteral obstruction caused by an inguinal hernia. A 52‐year‐old renal transplant recipient was admitted to our transplantation unit for abdominal pain and acute rise in serum creatinine level. Radiological work‐up showed that the distal transplant ureter was trapped in a left inguinal hernia. After placement of a temporary percutaneous nephrostomy tube and hernia repair by the Shouldice technique, the graft function improved and has remained stable at 1 year of follow‐up. Although infrequent, inguinal hernia can be a cause of obstructive uropathy and graft failure in a transplanted kidney, and the Shouldice technique is appropriate for cure of hernia in this setting. Dial. Transplant. © 2011 Wiley Periodicals, Inc.

Femoral herniation of transplanted ureter after deceased-donor kidney transplantation

“…We report, as evidenced in our case, that herniation of transplant ureter may lead to hydronephrosis, obstructive uropathy, and eventually transplant kidney failure [4,8] . We propose prompt diagnosis with transplant kidney ultrasound [9] or CT imaging of the abdomen and pelvis.…”

“…There are few cases of transplant ureters herniating into the abdominal wall. There are multiple case reports submitted where transplant ureter was incarcerated in inguinal hernias [1–6] . For the best of our knowledge this is the first reported transplant ureter herniated into the femoral canal.…”

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.…”