Different Management Options for Transplant Ureteral Obstructions within an Inguinal Hernia

Ureteral obstruction secondary to an inguinal hernia with transplant ureteral component is an extremely rare entity with only several case reports found in literature. In all previously reported cases, management of the obstruction involved temporary drainage with ureteral stenting or nephrostomy tube placements followed by delayed definitive repair. We present two case reports, here one being the first one managed by immediate definitive repair via ureteral reimplant and herniorrhaphy and a second case by delayed definitive repair after percutaneous nephrostomy tube placement. Both patients continued to do well postoperatively with normalization of renal function on follow-up.


Introduction
Transplant ureteral kidney obstruction is not an uncommon occurrence. Different causes of urinary obstruction in kidney transplants may include ischemia to distal ureteral segment, injury, stones, crossing vessels, lymphocele, or ureteral kinking [1]. Ureteral herniation through an inguinal hernia is an extremely rare cause of urinary obstruction, with only several reported cases in literature. Here, we present 2 cases of transplant ureteral herniation and the different approach to management. Both patients continued to do well with normalization of kidney function to baseline after relief of obstruction.

Case 1.
A 44-year-old obese white male with a history of ESRD secondary to childhood hemolytic-uremic syndrome, with post-DDRT status in 1998, presented with AKI with serum Cr of 3.4 mg/dL from his baseline of 2 mg/dL. He denied any symptoms. Exam was significant for a palpable left inguinal hernia. US revealed moderate to severe hydronephrosis of the transplanted kidney with nonvisualization of the distal ureter, and no bladder abnormalities. Despite IV hydration and adequate bladder emptying, the patient's urine output was marginal and Cr remained elevated at 3.1 mg/dL. A noncontrast CT of the abdomen and pelvis was obtained (Figure 1). A left inguinal hernia was seen to contain the distal transplant ureter with resultant proximal moderate to severe hydronephrosis of the transplant kidney, evident of obstruction.
The patient was taken to the operating room the next day for surgical exploration. A 2 × 3 cm defect between the internal oblique fascia and the shelving edge of the inguinal ligament was exposed, and a highly redundant transplant ureter was reduced ( Figure 2). The defect was repaired via preperitoneal approach with nonabsorbent sutures in interrupted fashion. The redundant transplant ureter was 2 Case Reports in Transplantation transected to an appropriate length and reimplanted into the anterior bladder wall over a ureteral stent.
Renal transplant hydroureteronephrosis has many etiologies, including ureteral obstruction, reflux, infection, and rejection. Hydronephrosis is usually identified by US while nuclear renal imaging with Lasix can further asses for obstruction. Cystoscopy with ureteral stenting or percutaneous nephrostomy placement can provide the usual first line options to relieve obstruction [1,2]. In rare instances, inclusion into an inguinal hernia can also cause transplant ureteral obstruction with only three other case reports in literature. Nonetheless, inguinal hernias should be considered in the differential diagnosis in the setting of transplant ureteral obstruction as they represent a common disease process in general and urologic surgical patients and one that urologists and transplant surgeons are able to treat. Factors that predispose to transplant ureteral obstruction include obesity and redundant ureteral length. Anterior positioning of the transplant ureter in relation to the spermatic cord also is a risk factor [1], although this was not the case for either of our two cases. Regardless of the predisposing influences, ureteroinguinal hernias can be categorized in three different ways depending on their proximity to peritoneum: paraperitoneal (next to peritoneal hernia sac), peritoneal (through peritoneal hernia sac), and extraperitoneal (not associated with a hernia sac altogether) [3]. Concomitant repair of inguinal hernias via a preperitoneal approach during pelvic urologic surgery, particularly with radical retropubic prostatectomy and radical cystoprostatectomy, has been described in the urologic literature [2].
All three prior reports of transplant ureteral obstruction due to inclusion into an inguinal hernia were managed by temporary placement of percutaneous nephrostomy tubes or ureteral stenting prior to delayed definitive surgery as with the scenario presented here in case 2 [1,4,5]. However, we also demonstrated that immediate and definitive repair of the ureteral obstruction with herniorrhaphy and ureteral reimplant is a feasible option. This case represents the first report of successful immediate repair of transplant ureteral obstruction. Given our patient's favorable outcome as measured by clinical status, rapid recovery, and Cr improvement, we show that when promptly diagnosed with the appropriate index of suspicion, immediate definitive herniorrhaphy with ureteral reconstruction is a feasible option for selected patients with transplant ureteral obstruction secondary to inclusion into an inguinal hernia.