1.       Introduction

Inguinal ureteral herniation is a rare and often misdiagnosed condition. When found intraoperatively, it may be challenging for a general surgeon performing a routine herniorrhaphy. As described in the literature, we can distinguish two types of ureteral herniation: intra- or extra- peritoneal. Up until October 2018, 166 cases were described in the English literature [1-15]. From an epidemiological viewpoint, this condition is often found in obese patients in their 50s-60s. As Allam et al. suggest, the abundant retroperitoneal fat that separates the ureter from the ipsilateral psoas muscle in obese patients with no urological disease may be the principal cause of herniation. Congenital anatomical abnormalities and postoperative variations of the urinary system have also been identified as risks factors.

In this case report, we describe the rare case of a patient presenting with a massive yet asymptomatic left inguinoscrotal hernia containing the ipsilateral ureter, loops of small bowel and colon, associated with complete left renal failure, urinary retention (3L were subsequently drained) and signs of prostatic malignancy documented by CT imaging.

2.       Case Presentation

A 69-year-old hypertensive man was referred to our Emergency Room by his family physician following his annual check-up during which a massive left inguinoscrotal hernia was found, associated with a palpable abdominal mass. It is worthy to note that he had been previously followed for his hernia but had refused a herniorrhaphy back in 2016. The patient was completely asymptomatic, was voiding normally and explained that the hernia had increased in size over the past 3 weeks.

Clinically, he was obese and a suprapubic mass was palpable, compatible with a distended bladder. Laboratory tests showed an elevated creatinine value of 140 micromol/L. Abdominal CT scan (Figure 1,2) revealed a distended bladder (containing 3L of urine) and a left inguinoscrotal hernia containing the ipsilateral ureter, the left colon and loops of small bowel. It also showed left hydronephrosis causing renal failure, most likely due to mass effect from possible malignancy arising from the prostate, in addition to two pulmonary nodules.

A urinary catheter was placed and the patient was taken to the operating room. He was found to have a massive indirect sliding inguinoscrotal hernia associated with intraperitoneal ureteral herniation, which was repaired according to the Rutkow herniorrhaphy technique. A ureteral stent (pigtail catheter) was not placed during the intervention as the patient was scheduled to undergo further urological investigation following the herniorrhaphy in order to rule out underlying prostatic malignancy. It is interesting to note that the value of the creatinine normalized in the postop phase, once the hernia was reduced.

3.       Discussion

As in the above case, inguinoscrotal ureteral herniation can be asymptomatic and only discovered intraoperatively, leading to a higher risk of iatrogenic ureteral lesions [16]. There are two types of ureteral hernias: para-peritoneal (80%) and extra-peritoneal (20%). According to Sidiqi MM et al, the para-peritoneal herniation is characterized by a peritoneal sac that indirectly engulfs the ureter into the wall of the hernia. This sac is not found in the extra-peritoneal hernia. When multiples structured are found in the hernia, it is important for the surgeon to be meticulous during the dissection as the ureter is often contained within the fat and must be reduced back into the retroperitoneal space following cord separation [9]. Abdominal CT imaging in the preoperative phase allows for characterization of the contents within the hernia. Allam et al. report that anterior deviation of the ureter may predict inguinoscrotal herniation (at the level of L4) [15]. In Figure 3, we can see that our patient had a ureteral deviation of 3cm at the level of L4-L5, in accordance with the above statement.

Intestinal ischemia and renal insufficiency are potential complications of this type of herniation. Ipsilateral hydronephrosis due to ureteral herniation should be monitored in the postoperative phase and a Pigtail stent should be placed if the renal function does not recover. As described by Eilber et al., incarceration is uncommon due to the size of the hernia [14].

4.       Conclusion

In this case report, we described a rare condition that can be found in asymptomatic patients. In obese patients with no past medical or surgical history of urological disease (namely renal transplantation), the surgical management of such cases is almost the same as in symptomatic inguinal hernias. According to the algorithm described by Yahya et al. [17], the surgeon should systematically investigate (via ultrasound and then CT) unexplained renal failure or urinary tract infections in patients presenting an inguinal hernia. Furthermore, they suggest that in cases of ureteral inguinal herniation, ureterocystoscopy with stenting should be realized before the inguinal hernia repair.

We believe that it is important to repair the hernia and restore the patient’s normal anatomy by open herniorrhaphy before proceeding with urological investigations as others urological procedures may not be necessary in the postoperative setting. As for the surgical technique, the literature agrees on using a tension free technique for the hernia repair. A laparoscopic approach is still not described in cases of ureteral inguinal herniation and we believe that further research in this domain is needed.

Figure 1, 2: Injected abdominal computed tomography in coronal (Figure 1) and sagittal (Figure 2) view (in venous phase) demonstrating herniation of ureter (arrow), small bowel (SB) with left hydroureteronephrosis (*) and distended bladder (B).

Figure 3: Abdominal computed tomography in axial view (injected, venous phase) showing the anterior ureteral deviation with a distance of 29 mm at L4-L5 level between psoas (P) and left ureter (U).

1. Bondevik H (1966) Inguinal prolapse of retroperitoneal fat (fatty hernia). A review and report of a case also involving the ureter. Acta Chir Scand 131: 492-496.
   
2. Morris LL, Caldicott WJH, Savage JP (1977) Inguinal herniation of the ureter. Pediatr Radiol 6: 107-108.
3. Percival WL (1983) Ureter within a sliding inguinal hernia. Can J Surg 26: 283-286.
4. Carnevale E, Cacchione O, Graziani M, Rizzuti M (1984) An unusual case of inguinal hernia with intestinal and ureteral content. Radiol Med 70: 641-642.
5. Burstein JD, Lipshitz S, Weinstein RJ, Boulinakis P, Seidman L, et al. (1986) Ureteral herniation: case report and literature review. Mt Sinai J Med 53: 134-136.
6. Rocklin MS, Apelgren KN, Slomsky CA, Kandzari SJ (1989) Scrotal incarceration of the ureter with crossed renal ectopia: case report and literature review. J Urol 142: 366-368.
7. Carpi R, Villari N (1997) Inguino-scrotal hernia of the ureter. A case report with computerized tomography findings. Radiol Med (Torino) 94: 692-693.
8. Giglio M, Medica M, Germinale F, Raggio M, Campodonico F, et al. (2001) Scrotal extraperitoneal hernia of the ureter: case report and literature review. Urol Int 66: 166-168.
9. Sisiqi MM, Menezes G (2018) Asymptomatic herniation of ureter in the routine inguinal hernia: A dangerous trap for general surgeons. Int J Sur Case Rep 49: 244-246.
10. Pucheril D, Chun B, Dalela D, Abdollah F, Laker SA, Rogers CG (2017) Robot-Assisted Laparoscopic Repair of Extraperitoneal Ureteral Inguinal Hernia with Mesh Placement. J Endourol Case Rep 3: 97-100.
11. Yahya Z, Al-Habbal Y, Hassen S (2017) Ureteral inguinal hernia: an uncommon trap for general surgeons. BMJ Case Rep 2017: bcr2017219288.
12. Ahmed S, Stanford R (2016) Ureteric obstruction secondary to a paraperitoneal inguinal hernia. Ann R Coll Surg Engl 98: 16-8.
13. Allam ES, Johnson DY, Grewal SG, Johnson FE (2015) Inguinoscrotal herniation of the ureter: Description of five cases. Int J Surg Case Rep 14: 160-163.
14. Eilber KS, Freedland SJ, Raifer J (2001) Obstructive uropathy secondary to ureteroinguinal herniation. Rev Urol 3: 207-208.
15. Allam ES, Johnson DY, Grewal SG, Johnson FE (2016) A sign on CT that predicts hazardous ureteral anomaly. Int J Surg Case Rep 22: 51-54.
16. De Carvalho Neiva R, Westin CEG, De Arruda JGF, Gatti M, Bogdan AP, et al. (2018) Inguinal hernia with ureter in patient with single kidney. AME Case Rep 2: 5.
17. Bugeja A, Clark EG, Sood MM, Ali SN (2018) As in Real Estate, Location Is What Matters: A Case Report of Transplant Ureteral Obstruction Due to an Inguinal Hernia. Can J Kidney Health Dis 5: 2054358117753620.