Paraureteric space post-ureteric re-implantation: a rare cause of small bowel obstruction

Background

An internal hernia (IH) is a protrusion of abdominal viscera through a peritoneal or mesenteric aperture into a compartment of the abdominal or pelvic cavity. The incidence of IHs is less than 1%; however, they cause 0.6%–5.8% of all small bowel obstructions.1 IHs can be acquired—for example, postsurgical, inflammatory or congenital—for example, paraduodenal or pericaecal. The incidence of postsurgical IHs is rising owing to increased numbers of transmesenteric, transmesocoloic and retroanastomotic surgical procedures.2 Nevertheless, pelvic IHs are extremely rare, and only a handful of cases of paraureteric small bowel obstruction have been reported.3–11 We report on an female patient in her 80s who presented with paraureteric small bowel obstruction 2 years after a robotic left distal ureterectomy and left ureteric re-implantation for a transitional cell carcinoma of the bladder and distal ureter.

Case presentation

A female patient in her 80s presented with a 2-day history of acute colicky central abdominal pain. She had associated absolute constipation and vomiting. On examination, she was dehydrated but haemodynamically stable, with a soft, moderately distended abdomen and mild tenderness in the periumbilical region. There were no signs of peritonism. On digital rectal examination, the rectum was empty.

Her medical history included hypertension, Graves’ disease (hypothyroid state) and high-grade transitional cell carcinoma (TCC) of the bladder and ureter. Additionally, she had been diagnosed with syndrome of inappropriate secretion of antidiuretic hormone with chronic hyponatraemia, migraines, atrial fibrillation (not anticoagulated), middle and posterior pelvic compartment prolapse, and mixed incontinence. She was on prophylactic antibiotics for recurrent urinary tract infections and intermittently self-catheterised. Her regular medications included amlodipine, atorvastatin, ramipril and levothyroxine, and she had no known drug allergies. She had been first diagnosed with a G2pT1 bladder TCC 17 years before and was treated with a transurethral resection of bladder tumour (TURBT). She subsequently had multiple recurrences within the bladder treated with a combination of repeat TURBTs, intravesical mitomycin and BCG. Four years prior to the current admission, she had been diagnosed with recurrence at the left distal ureter (G3pTa) and a year later, she underwent a robotic left distal ureterectomy with left ureteric re-implantation. At the time of the case presentation, she was in remission under surveillance with regular cystoscopies that showed inflammation and bladder mucosal ulceration only. She was independent of her activities of daily living and her WHO Performance Status was 1.

Investigations

Considering her history and presentation, a diagnosis of small bowel obstruction was entertained. Immediate resuscitation was initiated with intravenous fluids, nasogastric tube decompression and bowel rest. Analgesia, antiemetics and broad-spectrum antibiotics were administered, and appropriate investigations were organised. Her full blood count, biochemistry (renal and liver function tests, C reactive protein) and venous lactate were at her baseline (table 1).

CT of the abdomen and pelvis was reported in keeping with early closed-loop small bowel obstruction. There was dilated distal small bowel with faecalisation, and a transition point was located in the left side of the pelvis lateral to the urinary bladder. There was the impression of soft tissue encasing the left ureter, with resultant significant upstream left hydroureteronephrosis (figure 1).

Differential diagnosis

Differential diagnoses for this patient’s closed-loop small bowel obstruction included postoperative adhesional obstruction, local recurrence of TCC at bladder or ureter, peritoneal or omental disease, congenital band and abdominal wall herniation.

Treatment

Emergency multidisciplinary team discussion was undertaken, involving general surgery, urology, anaesthetics, intensive care and radiology specialists. Since the patient had normal renal function tests and the ureteric distention was likely chronic post re-implantation, a left ureteric decompression by ureteric stent was not deemed necessary. The possibility of TCC recurrence was entertained, but it was acknowledged that the patient would not have been suitable for radical redo ureteric or bladder resection. Therefore, the treatment options were exhausted in addressing the bowel obstruction only, irrespective of aetiology. The above was discussed with the patient and her family, and the relevant risks and benefits were detailed.

An emergency laparotomy was undertaken through the midline, under combination of general and spinal anaesthesia. The main finding was an internal herniation of the ileum just proximal to ileocaecal junction into the iatrogenic space formed by the previous ureteric re-implantation and bladder closure. This was defined by the distal ureter medially, the common iliac vessels laterally and the mobilised bladder dome anteriorly (figure 2). The herniated section of the small bowel was constricted (figure 3); this was reduced with gentle traction and after thorough inspection it was found to be viable, so no resection was required. In order to prevent recurrence of bowel herniation through the same fixed space, an omentoplasty was performed; omentum was mobilised off its attachment on the transverse colon and was transposed as a vascularised pedicle to ‘plug’ the paraureteric space. It was then fixed in place with non-absorbable 2-0 polypropylene sutures to the pelvic side wall and along its length on the parietal peritoneum of the lateral abdominal wall (figure 4). Peritoneal fluid was aspirated and sent for cytological analysis that proved to be normal, with no evidence of recurrence of neoplasia.

Outcome and follow-up

The patient had had an uneventful recovery on the ward, and after stepwise escalation of her diet, she returned to normal bowel habit. She was discharged home 1 week later without any complications. A follow-up CT was performed 6 weeks after the operation, which revealed normal bowel anatomy. Upon outpatient review, the patient reported a return to baseline with no ongoing gastrointestinal symptoms. She will continue to undertake bladder surveillance with the urology team.