Ureteroneocystostomy Herniation Leading to Obstructive Uropathy 10 Years Postrenal Transplant: a Rare Case Report

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Case Report

Ureteroneocystostomy herniation leading to obstructive uropathy 10 years postrenal transplant: A rare case report

Shailesh Chandra Sahay, Dilip Bhalla1, Pawan Kesarwani, Madan Sethi1 Departments of Urology and 1Nephrology, Max Superspeciality Hospital, Patparganj, Delhi, India

Abstract Herniation of the urinary bladder is observed in around 1%–4% of cases. Bladder herniation rarely presents with obstructive uropathy; however, bladder herniation carrying ureteroneocystostomy and leading to obstructive uropathy of the graft is even rare. Here, we present a case of a 36‑year‑old male with deranged renal function test who had undergone renal transplant 10 years back. Computed tomography scan revealed bladder herniation with ureteroneocystostomy and hydronephrosis. He was surgically explored by Gibson incision and ureterolysis, and hernioplasty was performed. Although the cause of herniation was ureteroneocystostomy, it was managed immediately without any need for percutaneous nephrostomy.

Keywords: Bladder hernia, transplant kidney, ureteroneocystostomy

Address for correspondence: Dr. Shailesh Chandra Sahay, Room No 1029, Department of Urology, Max Superspeciality Hospital, Patparganj, Delhi, India. E‑mail: [email protected] Received: 04.01.2019, Accepted: 04.10.2019, Published: 07.11.2019.

INTRODUCTION scan of the lower abdomen revealed hydroureter till its insertion in the bladder with an inguinal hernia and bladder Herniation of the urinary bladder is not rare; however, as its content [Figure 1b]. The urine culture was sterile, and around 1%–4% inguinal hernias may involve urinary the total leukocyte count was 8700 cells/µL. Cystoscopy bladder. Bladder herniation rarely presents with obstructive and exploratory laparotomy were planned. On cystoscopy, uropathy as it is mostly unilateral, and bladder herniation neoureteric orifice was patent, but stenting could not be carrying ureteroneocystostomy leading to obstructive done. Right Gibson incision was given, and bladder was uropathy of the graft is even rarer. Here, we present such seen herniating into the right inguinal canal [Figure 1c]. The a unique case, wherein the graft was salvaged in time. ureter was also being pulled out laterally, hence producing a kink that led to dilatation above this kink. It was an CASE REPORT extraperitoneal sliding type of hernia of the bladder. Ureter and bladder were carefully dissected, and Double‑J (DJ) A 36‑year‑old male presented with loss of appetite and stent was placed through a ureterotomy incision along decreased urine output. He had undergone transplantation with hernioplasty [Figure 1d]. The ureterotomy was of the right kidney 10 years ago [Figure 1a]. Ultrasound closed [Figure 1e]. The kidney function was normalized examination showed hydroureteronephrosis of the in 48 h. The patient had presented with obstructive transplanted kidney. The blood urea was 96 mg/dL, and the uropathy due to ureteric obstruction by a bladder hernia serum creatinine was 3.5 mg/dL. Computed tomography

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DOI: How to cite this article: Sahay SC, Bhalla D, Kesarwani P, Sethi M. 10.4103/UA.UA_2_19 Ureteroneocystostomy herniation leading to obstructive uropathy 10 years postrenal transplant: A rare case report. Urol Ann 2020;12:90-1.

Sahay, et al.: Ureteroneocystostomy in post renal transplant doing a PCN and achieved an excellent recovery of the graft immediately by surgical exploration. Early surgical exploration may also help in avoiding future stricture formation in the ureter.

CONCLUSION

a b c Ureteroneocystostomy herniation leading to obstructive uropathy in a transplanted kidney is a very rare entity. If detected early, surgical correction of a hernia and DJ stenting results in excellent graft recovery.

Declaration of patient consent The authors certify that they have obtained appropriate d e patient consent form. In the form, the patient has given his Figure 1: (a) Clinical picture showing inguinal hernia bulge, (b) consent for his images and other clinical information to be computed tomography scan coronal image showing herniated sac reported in the journal. The patient understands that his containing bladder with neoureteric orifice, (c) intraoperative image showing hernia sac in relation to ureter, (d) stent being placed from name and initial will not be published and due efforts will ureterotomy incision, and (e) operative image after Double‑J stenting be made to conceal their identity, but anonymity cannot and ureterotomy closure be guaranteed.

and improved immediately after hernioplasty and stenting. Financial support and sponsorship The stent was removed cystoscopically after 6 weeks. Nil.

DISCUSSION Conflicts of interest There are no conflicts of interest. Obstructive uropathy caused by bladder or ureteral herniation after renal transplant has been reported in the REFERENCES literature.[1] In most of the reported cases, the previous history of herniorrhaphy, which entangled the transplanted 1. Tran D, Gaboriault J, Collette S, Senécal L, Morin M, Boucher A, et al. Obstructive uropathy caused by an inguinal hernia in a kidney ureter, is presented. The most common type of a hernia transplant recipient: Report of hernia cure by the shouldice technique. found in these cases was an inguinal hernia. A bladder Dial Transplant 2011;40:413-4. hernia leading to ureteric obstruction and uropathy is 2. Weale AR, Baynham SJ, Pentlow AK, Pentlow BD. The impact of open mesh repair of inguinal herniae on renal transplantation. very rare. Transplantation 2007;84:938. 3. Azhar R, Boutros M, Hassanain M, Polyhronopoulos G, Chaudhury P, Hernia repair with the use of mesh has greatly reduced Tchervenkov J, et al. A rare case of obstructive uropathy in renal the risk of recurrence.[2] In most of these cases, it was transplantation: Ipsilateral indirect inguinal herniation of a transplant observed that the prognosis of the surgery was good ureter. Transplantation 2009;88:1038‑9. 4. Furtado CD, Sirlin C, Precht A, Casola G. Unusual cause of ureteral and also the kidney graft function was retained, while in obstruction in transplant kidney. Abdom Imaging 2006;31:379‑82. other cases, patients were usually managed first by putting 5. Ingber MS, Girdler BJ, Moy JF, Frikker MJ, Hollander JB. Inguinal a percutaneous nephrostomy (PCN) and stabilizing herniation of a transplant ureter: Rare cause of obstructive uropathy. Urology 2007;70:1224.e1‑3. the kidney function and then going for the definitive 6. Osman Y, Ali‑El‑Dein B, El‑Leithy R, Shokeir A. Sliding hernia [3‑9] procedure. containing the ureter – A rare cause of graft hydroureteronephrosis: A case report. Transplant Proc 2004;36:1402‑4. Ghielmini et al. reported a similar case as ours with a bladder 7. Sánchez AS, Tebar JC, Martín MS, Bachs JM, Moreno MJ, Navarro HP, [9] et al. Obstructive uropathy secondary to ureteral herniation in a hernia, but it had caused acute urinary obstruction. They pediatric en bloc renal graft. Am J Transplant 2005;5:2074‑7. managed the case with PCN diversion first followed by 8. Neumayer L, Giobbie‑Hurder A, Jonasson O, Fitzgibbons R Jr., open antegrade stenting.[9] In our case, the obstruction Dunlop D, Gibbs J, et al. Open mesh versus laparoscopic mesh repair was insidious in onset, and the patient was clinically of inguinal hernia. N Engl J Med 2004;350:1819‑27. 9. Ghielmini E, Julita L, Cerantola Y, Matter M, Zingg T. Inguinal stable with a serum creatinine of 3.5; hence, we planned bladder hernia with acute ureteral obstruction 14 years after kidney to do a straightforward surgical correction. We avoided transplantation: A case report. Transplant Proc 2017;49:1593‑5.

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