Robot-Assisted Laparoscopic Repair of Extraperitoneal Ureteral Inguinal Hernia with Mesh Placement

Abstract

Background: Ureter involvement within indirect hernias is a rare phenomenon usually identified incidentally during herniorrhaphy. Even more rare are extraperitoneal ureteral inguinal hernias, which represent about 20% of these cases and are characterized by a substantial amount of extraperitoneal fat in the hernia defect, the absence of a peritoneal sac, and associated with hydroureteronephrosis and nephroptosis. To date, repair of ureteral inguinal hernias has been performed exclusively using open surgical techniques. We report the first case of successful robot-assisted laparoscopic repair of this rare presentation.Case Presentation: A morbidly obese 70-year-old male with an unremarkable surgical and urological history presents with a 15-year history of nonpainful, enlarging right scrotal swelling measuring 25 cm in diameter. CT imaging revealed right nephroptosis and a hernia defect containing a dilated right ureter looping into the scrotum surrounded by significant extraperitoneal fat. Retrograde pyelography and ureteral catheter placement confirmed a >100 cm ureter. The patient underwent a robot-assisted laparoscopic repair. The inferior epigastric artery, spermatic cord vessels, vas deferens, and ureter were identified. The defect was reduced using external scrotal pressure and reinforced with ProGrip™ self-fixating laparoscopic mesh. The patient was discharged 2 days later following an uneventful postoperative course.Conclusion: Although rare and usually incidentally discovered, extraperitoneal ureteral inguinal hernias can be identified preoperatively by the astute clinician. Preoperative identification allows for improved surgical planning, including a minimally invasive approach. Robot-assisted laparoscopic repair with mesh placement is a feasible alternative to traditional open techniques.

Laparoscopic Repair of Extraperitoneal Ureteral Inguinal Hernia With Mesh Placement

“…The surgical approach in treating these hernias usually consists of ureteral protection with cystoscopy and stent placement, followed by open repair and reduction. The laparoscopic approach has been previously described in the management of urinary bladder hernias [6], but to our knowledge, there are only several case reports describing a minimally invasive approach for repair of ureteral hernias [7][8][9]. Our case report shows that, in situations where a robotic system is not available, a laparoscopic approach combined with distal stenting of the ureter may be a better option to decrease the risk of injury to the ureter.…”

Inguinal hernia of the distal ureter causing hydronephrosis: A rare case

“… 1 Since then, less than 200 cases have been reported in the published literature. 2 There are two variations among hernias involving the ureter – para-peritoneal (80%) and extraperitoneal (20%) – both of which are usually via indirect herniation. 3 To our knowledge, there have been only 2 cases of robot-assisted laparoscopic repair, with only one of involving the ureter without concurrent bladder herniation.…”

“… 3 To our knowledge, there have been only 2 cases of robot-assisted laparoscopic repair, with only one of involving the ureter without concurrent bladder herniation. 2 , 4 We present a case of a left distal ureter herniated within the left inguinal canal, and subsequent robot-assisted left inguinal hernia repair with mesh.…”

Obstructive uropathy secondary to a ureteral paraperitoneal inguinoscrotal hernia in a patient with a pelvic ectopic solitary kidney and malrotation: a case report and review of the literature

“…6 Algorithm for ruling out and diagnosing ureteral inguinoscrotal hernia, adapted from Yahya et al [1]. UTI urinary tract infection, US ultrasound, CTU computed tomography urogram the experience of an open approach herniorrhaphy with mesh and two cases of robotic-assisted surgery have been reported [16,17].…”