|Year : 2022 | Volume
| Issue : 3 | Page : 337-339
Successful surgical repair of inguinal hernia causing positional obstructive uropathy: A rare cause of renal graft dysfunction - Case report
K S. N S. Udhbhav1, RM Meyyappan1, J Saravanan1, V Jayaprakash2
1 Department of Urology, SRM Medical College Hospital and Research Centre, SRMIST, Kanchipuram, Tamil Nadu, India
2 Department of Nephrology, SRM Medical College Hospital and Research Centre, SRMIST, Kanchipuram, Tamil Nadu, India
|Date of Submission||13-Sep-2021|
|Date of Acceptance||28-Mar-2022|
|Date of Web Publication||30-Sep-2022|
Dr. K S. N S. Udhbhav
Flat 3018, 3B Block, Appaswamy Banyan House, Near Alandur Court, MKN Road, Alandur, Chennai - 600 016, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Bladder herniation with obstructive uropathy is a relatively rare occurrence, however, urinary bladder herniation along with ureteroneocystostomy and leading to positional obstructive uropathy of the graft is an unusual presentation. This is a unique case of a 38-year-old male who presented with inguinal hernia with raised serum creatinine who had undergone renal transplant 10 years back in 2011. Magnetic resonance urogram revealed herniation of urinary bladder and hydroureteronephrosis of transplant kidney. Patient is managed by surgical exploration through inguinal incision and reduction of ureteroneocystostomy herniation after ureterolysis and hernioplasty was performed. The cause of obstructive uropathy was herniation of the bladder along with ureteroneocystostomy, and the patient has an insidious onset of symptoms, immediate exploration, and repair of hernia done without any need for percutaneous nephrostomy. Importance of this case report is that sliding herniation of the bladder with ureteroneocystostomy should be considered a diagnosis and investigated if the patient presents with positional obstructive uropathy with inguinal hernia, leading to early identification and salvaging the graft function.
Keywords: Bladder hernia, positional obstructive uropathy, transplant kidney, ureteroneocystostomy
|How to cite this article:|
Udhbhav K S, Meyyappan R M, Saravanan J, Jayaprakash V. Successful surgical repair of inguinal hernia causing positional obstructive uropathy: A rare cause of renal graft dysfunction - Case report. Indian J Transplant 2022;16:337-9
|How to cite this URL:|
Udhbhav K S, Meyyappan R M, Saravanan J, Jayaprakash V. Successful surgical repair of inguinal hernia causing positional obstructive uropathy: A rare cause of renal graft dysfunction - Case report. Indian J Transplant [serial online] 2022 [cited 2022 Nov 27];16:337-9. Available from: https://www.ijtonline.in/text.asp?2022/16/3/337/357618
| Introduction|| |
Bladder herniation rarely causes obstructive uropathy as it is unilateral in most cases, and bladder herniation along with ureteroneocystostomy causing positional obstructive uropathy of the graft is very rarely seen. In most of the cases of inguinal hernia with obstructive uropathy, the cause is ureteric herniation due to sliding of the ureter through the neck of hernia as isolated content or along with the peritoneal sac or entrapment of ureter or injury during hernia repair. Here, we present in contrast a unique case of sliding herniation of urinary bladder with ureteroneocystostomy site who presented with positional obstructive uropathy on standing and walking, wherein the graft function recovered with early management.
| Case Report|| |
A 38-year-old male presented with right inguinal mass with decreased urine output on standing or walking but improved and normal output in supine position, especially during the night and with slowly progressing azotemia after developing hernia with an increase in serum creatinine from 1.5 to 2.5 mg/dl over a period of 6 months. He had a medical history of end-stage chronic kidney disease with Alport's syndrome, systemic hypertension and had undergone deceased donor renal transplantation 10 years ago [Figure 1], immediate posttransplant patient developed renal calcineurin inhibitor toxicity underwent renal biopsy done and baseline serum creatinine was 1.5 mg/dl, he was on triple immunosuppressants: tacrolimus, mycophenolate mofetil, and steroids. Ultrasound examination showed transplant kidney hydroureteronephrosis. The blood urea was 46 mg/dL, and the serum creatinine was 2.5 mg/dL at the time of admission. Magnetic resonance urogram showed hydroureteronephrosis till ureteric insertion into the urinary bladder with sliding inguinal herniation of the bladder [Figure 2]. No organism was isolated on urine culture, and the total white blood cell count was 7600 cells/μL. Inguinal exploration and hernioplasty were planned. Right inguinal incision given and on exploration a direct hernial sac with sliding herniation of bladder forming the medial wall of the sac is identified [Figure 3]. The ureter was also being pulled out causing a kink, and there are adhesions of the ureter to the bladder which caused dilatation. It was a sliding hernia of the urinary bladder along with ureteroneocystostomy. Ureter and bladder adhesions with the sac were carefully released and ureterolysis [Figure 4] done along with hernioplasty with meshplasty [Figure 5]. The kidney function improved within 48 h and serum creatinine reduced from 2.5 to 2 mg/dl and total output per day also improved. One-month postprocedure follow-up, the patient is devoid of any symptoms.
|Figure 2: Magnetic resonance UROGRAM showing dilated transplant ureter (blue arrow)|
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|Figure 3: Sliding bladder (blue arrow) with adjacent direct hernial sac (red arrow)|
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| Discussion|| |
Concurrent herniation of the urinary bladder along with ureteroneocystostomy causing positional obstructive uropathy as described in this case is rare and only published few times in literature.,,,,, In most of the other reported cases, the cause of obstruction is entanglement of transplant ureter during mesh repair and isolated ureteric herniation.,, Sliding inguinal hernia of the urinary bladder causing allograft hydronephrosis due to ureteric obstruction and positional obstructive uropathy is a rare entity seen in this case.
Hernia repair with mesh has significantly decreased the recurrence rates. The prognosis after surgery is good with early recovery of graft function, in some cases of acute obstruction diversion needed in the form of nephrostomy for stabilizing the kidney function and then proceeding for definitive procedure.
Ciancio et al. reported a similar case with ureteroneocystostomy and positional obstructive uropathy. In our case point of observation is that patient had changes in urine output with change in position from lying down to standing due to herniation which point toward ureteroneocystostomy herniation causing obstruction leading to positional obstructive uropathy.
Ghielmini et al. reported a case similar to ours with sliding hernia of the urinary bladder but with acute obstruction. The patient was managed with percutaneous nephrostomy diversion first and then by antegrade stenting. In our case, as the patient was clinically stable with no acute obstruction and slowly progressing azotemia an early surgical exploration and hernioplasty was done. Immediate surgery helps in preventing further graft loss and avoids further insult to the ureter and transplanted kidney.
Sahay et al. reported a case similar to ours with a urinary bladder hernia causing obstructive uropathy, insidious in onset underwent ureterolysis, hernioplasty, ureterotomy, and DJ stenting. In our case, ureterotomy and stenting were not performed, as after ureterolysis, peristalsis of the ureter and urine output was well maintained without any intraluminal obstruction requiring DJ stenting.
| Conclusion|| |
Sliding herniation of the urinary bladder along with ureteroneocystostomy causing positional obstructive uropathy in a posttransplant patient is a very rare presentation. Herniation of the transplant ureter or sliding herniation of urinary bladder and ureteroneocystostomy should be considered when investigating the cause of obstructive uropathy in posttransplant patients presenting with inguinal hernia and decreased urine output. Early detection and management helps in preventing graft loss and early graft recovery.
Declaration of patient consent
The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. The patient understands that name and initials would not be published, and all standard protocols will be followed to conceal his identity.
The completion of this case report would not have been possible without participation and assistance from all the authors mentioned in this case report; we thank each other for the efforts put forth and compilation of materials and images in making this case report. Above all, we thank almighty for granting us wisdom and knowledge to compile this case report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]