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Translational Research in 11 (2018) 5–9

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Translational Research in Anatomy

journal homepage: www.elsevier.com/locate/tria

Ureterosciatic hernia: An up-to-date overview of evaluation and T management

∗ Jason Gandhia,b,c, Min Yea Leea, Gunjan Joshid, Noel L. Smithe, Sardar Ali Khana,f, a Department of Physiology and Biophysics, Stony Brook University School of Medicine, Stony Brook, NY, USA b Medical Student Research Institute, St. George's University School of Medicine, West Indies, Grenada c Department of Anatomical Sciences, St. George's University School of Medicine, West Indies, Grenada d Department of Internal Medicine, Stony Brook Southampton Hospital, Southampton, NY, USA e Foley Plaza Medical, New York, NY, USA f Department of Urology, Stony Brook University School of Medicine, Stony Brook, NY, USA

ARTICLE INFO ABSTRACT

Keywords: Ureterosciatic hernia, defined as a suprapiriform or infrapiriform herniation of the pelvic ureter, is the sliding of Ureter the ureters into the pelvic fossa, fovea, or greater or lesser sciatic foramen. This type of hernia is the rarest form Sciatic hernia of pelvic sciatic hernias. It may cause a wide range of cryptic clinical symptoms of pain, obstructive uropathy, Ureteral obstruction sepsis, or renal failure. This condition has been described in terms of involvement in inguinal, femoral, sciatic, Sepsis obturator, and thoracic regions. A high index of clinical suspicion is essential for diagnosis because the hernia Hydronephrosis develops in the and becomes overlayed by the large gluteal muscle. Since ureterosciatic hernias Renal failure have not been adequately reviewed in the literature due to the limited number of case reports, we aim to aid the clinician's knowledge by discussing the relevant anatomy, classification, clinical symptoms, optional radiology, optional diagnostic instrumentation, and management. Treatment options include non-surgical and surgical intervention. Vena caval filters may be preoperatively indicated due to the proximity of the pelvic venous vasculature in the surgical field. Treatment must also be mandated for intraoperative and postoperative vascular, neurological, and other anticipated complications of complex ureterosciatic hernia repair.

1. Introduction treatment are essential for optimal recovery. The aim of this review is to increase visibility and provide management options to clinicians in- Ureterosciatic hernia (i.e., the suprapiriform or infrapiriform her- experienced with this condition. Initially, we review the relevant clin- niation of the pelvic ureter) is the rarest form of sciatic hernia with less ical anatomy due to its importance for laparoscopic and robotic surgery. than thirty published reports worldwide [1,2]. Sciatic hernia occurs as (see Tables 1–10, Fig. 1) the peritoneal sac and its contents protrude through the greater or lesser sciatic foramen. Ureterosciatic hernia results as the ureter be- 2. Overview of pelvic anatomy comes involved in the herniated contents to cause acute or chronic results [3]. Herniated contents may contain the ovary, small intestine, The greater sciatic foramen is the passageway for all vessels and colon, greater omentum, or even neoplasm(s). Herniation of the ureter to pass through to enter the gluteal region. The sacrotuberal into the greater sciatic foramen usually results from the piriformis ligament, , and greater sciatic notch form the muscle weakening from increased pressure in the intra-abdominal area greater sciatic foramen [7]. With the lesser sciatic notch, the lesser due to pregnancy, severe constipation, surgery, trauma, as well as sciatic foramen is made. The connects the sa- neuromuscular or diseases. It is commonly acquired but may be crum to the . The sacrospinous ligament connects the congenital [4]. A ureterosciatic hernia may afflict both children and to the . The posterior side of the greater sciatic adults, but female adults aged 40 to 60 are at greater risk due to a notch binds the greater foramen anteriorly and superiorly, posteriorly generally wider pelvic [5,6]. Due to the extreme rarity of the by the sacrotuberous ligament and inferiorly by the sacrospinous liga- condition, an effective and reliable long-term prognosis has yet to be ment. It mostly filled up by a pear-shaped muscle called the piriformis established. However, early diagnosis and appropriate target of muscle. The piriformis muscle divides the foramen into the

∗ Corresponding author. Department of Urology, Health Sciences Center T9-040, Stony Brook University School of Medicine, 101 Nicolls Road, Stony Brook, NY 11794-8093, USA. E-mail address: [email protected] (S. Ali Khan). https://doi.org/10.1016/j.tria.2018.04.002 Received 23 November 2017; Received in revised form 11 April 2018; Accepted 17 April 2018 Available online 21 April 2018 2214-854X/ © 2018 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). J. Gandhi et al. Translational Research in Anatomy 11 (2018) 5–9

Fig. 1. Passage of the intrapelvic ureter. (a) Normal passage of the ureter. (b) Ureter herniating into the greater sciatic foramen. suprapirifomis and infrapiriformis area. The superior gluteal artery, as genitourinary organs. The umbilical artery, a branch of the internal , and are present above the piriformis muscle. Most hernias iliac artery, supplies the upper part of bladder while the inferior vesical are observed through the suprapiriformis region following the superior artery supplies the lower part of the bladder and the prostate. The gluteal artery and nerve. Below it, the inferior gluteal vessels and nerve, uterine and vaginal arteries, which are also branches of the internal internal pudendal vessels, , sciatic and posterior femoral iliac artery, supply these respective reproductive organs in females cutaneous nerves, and nerves to the quadratus femoris muscle and [10]. The vascular supply of the is outlined in Table 2. obturator internus are present [8]. In females, the abdominal opening of the sac is posterior to the The sacrospinous ligament and ischial spine bound the lesser sciatic broad ligament just above the uterosacral ligament. In males, the in- foramen superiorly, anteriorly by the ischial tuberosity, and posteriorly ternal opening is between the rectum and bladder in the posterior lat- by the sacrotuberous ligament. The internal pudendal vessels and eral pelvis [11]. nerve, obturator internus nerves, and quadratus femoris muscle nerves that exited pelvis through the greater sciatic foramen re-enter the pelvis 3. Evaluation via the lesser sciatic foramen [8]. In the pelvis, the sac of the suprapiriformis hernia lies in front of the 3.1. Clinical presentation piriformis muscle, involving some roots of the sciatic nerve as well as the superior gluteal vessels and nerve. The sciatic nerve is formed in the Depending on the etiological factors and structure of the affected posterior portion of the pelvis by the ventral rami of the L4-S3 roots. It region, ureterosciatic hernia symptoms will vary and may present with leaves the pelvis through the greater sciatic foramen below the pir- other sciatic hernia sign. General symptoms include swelling near the iformis. As it descends between the greater trochanter and the ischial affected area, as well as a feeling of pressure and flank pain in the pelvic tuberosity in the gluteal area, the nerve divides into common peroneal region, particularly in women [18]. A palpable mass is not always nerve and tibial nerve. The pudendal nerve, from anterior branches of present. If the sciatic nerve is compressed, there may be an associated S2-S4, runs through the greater sciatic foramen inferior to the pir- manifestation of bowel obstruction, gluteal pain, and radiating pain iformis muscle, but loops back through the lesser sciatic foramen to through the posterior thigh exacerbated by dorsiflexion of the foot [19]. enter the . It provides motor innervation to the perineum Clinical presentation can be minor to life-threatening due to the muscles and sensory innervation to the genitalia [9]. Table 1 lists the size, location, and herniated contents [1]. Obstructive uropathy is a nerves arising in the pelvic cavity. rare result of a ureterosciatic hernia with minimal cases reported in the Partitions of the iliac artery system supply blood to the pelvic re- literature [20]. In severe cases, pyelonephritis and urinary sepsis have gions of the body such as the gluteal muscles, hip joints, thighs, as well been reported [5]. There are implications of bilateral hydronephrosis and hydroureter [21,22]. With hydronephrosis, renal colic tends to be Table 1 present as well [23]. Table 3 summarizes the clinical presentation of Pelvic cavity nerves.

Sciatic nerve [9] Table 2 Tibial nerve Arterial (branches of the common iliac and internal iliac arteries) and venous fi Common bular (peroneal) nerve (branches of the common iliac and internal iliac ) supply of the pelvic Superior gluteal nerve [12] cavity [12]. [13] Nerve to quadratus femoris muscle [14] Arterial vessels of the pelvis Venous vessels of the pelvis Nerve to obturator internus muscle [14] Posterior femoral cutaneous nerve Superior and inferior gluteal Rectal venous plexus Pudendal nerve [8] Iliolumbar Pudendal internal Perforating cutaneous nerve [8] Internal pudendal Uterovaginal plexus Lateral sacral Vesical plexus Nerve to piriformis muscle [15] Middle rectal Nerve to coccygeus and muscle [16] Obturator Pelvic splanchnic nerve [17] Umbilical Perineal branch of sacral 4 [17] Vaginal Hypogastric nerve [14] Uterine Sacral splanchnic nerve [17] Inferior and superior vesical

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