Ureteral inguinoscrotal hernia recurrence following robotic hernia repair: an uncommon hernia recurrence
- 1 Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
- 2 Urology, Hackensack University Medical Center, Hackensack, New Jersey, USA
- Correspondence to Dr Burton Surick; burton.surick@hmhn.org
Abstract
Ureteral inguinoscrotal hernias are a rare occurrence and commonly occur without evidence of obstructive uropathy. We present a patient found on a preoperative CT scan to have a recurrent left inguinal hernia with the left ureter passing through the hernia defect adjacent to the hernia sac into the scrotum. At surgery the redundant dilated ureter required a ureteroureterostomy because it could not be safely straightened or reduced. Preoperative imaging allowed for identification of the ureter in the hernia sac and allowed for extensive preoperative planning with the urology team, and efficient definitive treatment of his condition at the time of surgery.
Background
Ureteral involvement in groin hernias is a rare occurrence with approximately 140 cases reported in the literature, and the first documented case was reported by Leroux in 1880.1 In general, ureteral hernias are more common on the right than the left as the fascia of Toldt at the level of the secondary root of the mesosigmoid is believed to fix the ureter in the retroperitoneum when it is well developed.2
Ureteral involvement with inguinal hernias is usually associated with indirect inguinal hernias. Ureteral involvement can be categorised as either paraperitoneal or extraperitoneal. Paraperitoneal ureteral hernias occur when the ureter becomes adhered to or otherwise incorporated into the peritoneal wall and herniates with bowel. The ureteral association with the peritoneal wall can be due to adhesions from previous surgery or traction from other sliding organs. Paraperitoneal hernias account for 80% of ureteral hernias.3
Extraperitoneal hernias typically involve ureter herniating with retroperitoneal fat but no discrete hernia sac. They are believed to be associated with failure of the ureteral bud to separate from the Wolffian duct, leading to the fusion of the ureter to the genitoinguinal ligaments.4
In the rare event that there is ureteral involvement in an inguinal hernia, patients usually do not have signs of obstructive uropathy which therefore leads to an intraoperative rather than preoperative diagnosis.5
Case presentation
We present the case of a man in his sixties who developed pain and swelling in the left groin after heavy lifting for the last 2 months. He stated that he had a robotic/laparoscopic repair of inguinal hernias with mesh at another hospital in 2017 as well as an open appendectomy in the distant past. He presented to our emergency department (ED) because of worsening abdominal pain. In the ED, he was found to have a left-sided inguinal hernia that was reducible without signs of strangulation or obstruction. Routine labs and a CT Scan of the abdomen and pelvis was obtained as part of the evaluation of his abdominal pain. He was discharged from the ED and presented for further workup and elective surgery to address his hernia.
Investigations
The patient was seen in the surgeon’s office and on examination there were multiple healed transverse scars consistent with previous laparoscopic surgery. There was evidence of a left recurrent hernia which was easily reducible and no evidence of a recurrence on the right side. Both of his testicles were normal. The routine labs from the ED included a complete blood count with differential, comprehensive metabolic panel & urinalysis which were all within normal limits. As part of our routine preparation for any recurrent hernia surgery an attempt was made to obtain the old operative report and records however we were unsuccessful. We also routinely obtain a CT Scan to better assess the post operative anatomy.
The CT scan of the abdomen and pelvis which had been obtained through the ED demonstrated a left sided fat-containing recurrent scrotal hernia with the left ureter passing into the hernia defect. There was associated mild to moderate left hydroureteronephrosis (figure 1) and there was no evidence of any recurrence on the right side. The patient was also seen preoperatively by urology and an in-office cystoscopy was performed which showed an enlarged prostate, no masses in the bladder and normal ureteral orifices.
CT images demonstrating left-sided hydronephrosis (green arrow) and ureteral involvement in left inguinal hernia (red arrows).
Treatment
The patient was brought to the operating room by general surgery and urology for a combined open surgical procedure. The lower abdomen including the penis and scrotum were prepped for the procedure. The left inguinal region was explored through a standard inguinal incision. There was minimal scarring and any preperitoneal mesh from the prior repair was not appreciated. The hernia sac, cord structures and ureter were clearly delineated and were all separated. A direct hernia passing through the internal ring was identified as well as the separate 15 cm. loop of dilated, atretic left ureter (figure 2). The hernia sac was easily reduced and then the Urology team performed a cystoscopy and attempted to reduce and straighten the ureter by passing a stent with fluoroscopic and cystoscopic assistance. However these manoeuvres were unsuccessful (figure 3).
Surgical dissection showing cord structures (white arrow), hernia sac (green arrow), ureter (dashed arrow).
Intraoperative fluoroscopy demonstrating redundant ureter as visualised by loop of guidewire.
It was decided to resect a portion of the redundant ureter and perform an end-to-end uretero-ureteral anastomosis over a double—J stent (figures 4 and 5). The straightened ureter was safely reduced back into the retroperitoneum, and the ureter was no longer redundant or visualised (figure 6). At this point, the herniorrhaphy was completed as a Lichtenstein repair using a prolene mesh and a penrose drain was placed into the retroperitoneal space through a separate stab incision near the ureteral anastomosis in case there was any collection of urine. The patient was discharged that day with a foley catheter to a leg bag and a 5-day course of oral cephalosporin antibiotics.
Stent and guidewire passing through ureter during resection of redundant segment.
Suturing of end-to-end uretero-ureterostomy anastomosis.
Intraoperative fluoroscopy demonstrating resolution of redundancy after ureteral resection and primary anastomosis.
Outcome and follow-up
Following surgical intervention, the patient has done well. His penrose drain was removed on postoperative day 2, the foley catheter was removed on postoperative day 5 and the double-J stent was removed 6 weeks after his procedure. At a 4-month follow-up visit, the patient had no abdominal complaints since his hernia repair with ureteroureterostomy. He has had no issues with erections, bowel movements, or urinating. On exam there there was no evidence of any recurrence of the hernia or infection of the mesh. He is currently taking tamsulosin for benign prostatic hypertrophy. The pathology from the resected ureter showed a segment of markedly dilated ureter with oedema, mild chronic inflammatory and reactive changes and no evidence of malignancy.
Discussion
This patient was found to have a direct inguinal hernia emerging through the internal ring, with associated left ureter herniation. Occasionally, ureteral hernias can be found during the course of investigation of other pathology, as described in Lu and Burstein where inguinal ureteral herniation was found in the workup of renal failure.6 While our patient did have radiographic evidence of ureteral obstruction, he did not have any indication of renal insufficiency.
Ahmed and Stanford reported a similar case of a patient found to have left hemi-scrotal swelling caused by a sliding inguinal hernia involving ureter, with ipsilateral hydronephrosis.7 Ultrasonography and retrograde pyelography can be useful tools when evaluating for ureteric obstruction in the presence of inguinoscrotal swelling. As described by He et al, evaluation of this entity typically demonstrates a ‘curlicue’ or ‘loop the loop’ sign, as seen in figure 5, which is pathognomonic for ureteral hernia.8 This finding was clearly demonstrated intraoperatively in our patient after having identified the ureter in the hernia sac on the preoperative CT scan. A preoperative retrograde pyelography could have also been performed to confirm the ureteral involvement prior to surgery but was not necessary.
Urinary tract obstruction caused by a ureteral hernia can lead to complications such as infection or renal calculi. Yahya et al report a patient found to have an Escherichia coli urinary tract infection with further workup demonstrating renal calculi 5 cm from the vesicoureteral junction. Their patient had a known history of inguinal hernias, but CT urogram demonstrated ureteral involvement which required hernia repair prior to successful ureteral stenting and stone removal.9 They recommend stenting the ureter preoperatively to facilitate identifying, reducing, and preserving the ureter. In our case, stenting and reduction of the dilated ureter was not possible in the operating room and therefore a ureteroureterostomy was necessary to straighten the ureter and treat the patient.
Golgor et al described an extraperitoneal ureteral hernia that they believed to be the first report of a ureteral hernia occurring as part of a hernia recurrence. They found only ureter in the hernia and hypothesised the prior hernia repair may have caused adhesions between the ureter and the peritoneum which ultimately resulted in pulling the ureter into the scrotum.10 Our case demonstrates the ureter separate and apart from the recurrent hernia sac, but a similar adhesive mechanism is still very plausible. At surgery the prior mesh was not able to be identified in the preperitoneal space and the old operative reports from an outside hospital was not available to know specifically what operation was performed. We hypothesise that he had a robotic/laparoscopic transabdominal preperitoneal hernia repair with mesh. The ureteral herniation was probably present at his prior surgery but the indirect ring was not adequately dissected or covered by the mesh. The ureteral herniation continued to enlarge as the recurrent hernia became symptomatic.
Regardless of aetiology, ureteral hernias are typically incidental findings given their rarity and tendency to present asymptomatically. Epps and Close describe an incidental diagnosis of an extraperitoneal hernia during evaluation for suspected bowel obstruction.11 Their patient’s hernia demonstrated only ureteral involvement, without evidence of hernia sac in the inguinal canal and was thus classified as extraperitoneal. In our case, hernia sac, cord structures and ureter were identified at surgery. However, the hernia appeared to be direct, without an adherent peritoneal sac to the cord structures or ureter. in the internal inguinal ring. Classification of the ureteral hernia in our case is somewhat difficult, however it may be appropriate to describe it as an extraperitoneal hernia given the lack of adhesions to the hernia sac and the ureter’s course through the inguinal ring despite absence of the hernia sac.
Prieto et al reported outcomes following ureteroureterostomy using inguinal herniorrhaphy type incisions and found it to be a successful technique for the procedure.12 At times other urogenital structures can be involved, including the spermatic cord which may require resection and anastomosis.13
The most common scenario in which the ureter is included in an inguinal hernia is in the renal transplant population. Hakeem et al reported a case involving a redundant ureter that was anastomosed over the spermatic cord, leading to inguinal herniation and obstruction with graft dysfunction. Their repair consisted of excising the distal ureter and anastomosing the proximal segment underneath the spermatic cord to reconstitute a more normal anatomic configuration.14 Other similar cases are reported in the literature.15
Patient’s perspective
I was very appreciative of the combined approach to address my hernia. I felt that my recovery was even easier than after the robotic hernia repair and I have returned to all activities without any limitations.
Learning points
-
Ureteral hernias are rare, and more often discovered intraoperatively as opposed to preoperatively.
-
Ureteral hernias are often asymptomatic, therefore a high index of suspicion is necessary during investigation.
-
Preoperative CT scans are useful when evaluating recurrent hernias.
-
Preoperative coordination with urology allowed for efficient, appropriate patient care.
-
Care must be taken to protect the ureter during hernia repair.
Ethics statements
Patient consent for publication
Footnotes
-
Contributors The contribution to the manuscript for the four authors are as follows; BS: conceptualisation, analysis, review and editing. KB: conceptualisation, review. NC: resources and review. AK: resources writing-original draft.
-
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
-
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
-
Competing interests None declared.
-
Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
Use of this content is subject to our disclaimer