CASe RePORT

Inguinal Herniation of a Transplant Ureter: Lessons Learned From a Case of “Water Over the Bridge”

Abdul R. Hakeem,1 Palanivel Gopalakrishnan,1 Mohantha D. Dooldeniya,1

Henry C. Irving,2 Niaz Ahmad1

Abstract

Inguinal herniation of the transplant ureter is rare,and there is a paucity of reports in the literature.Herniation is usually secondary to implanting a longredundant ureter and may be precipitated by itscourse over the spermatic cord. Most often, there isloss of the allograft owing to delayed presentationand chronic ureteric obstruction. Here, we report acase of inguinal herniation of a transplant ureter withobstruction and graft dysfunction.

A 72-year-old man presented 9 years afterdeceased-donor kidney transplant, with progressivegraft dysfunction and a symptomatic right inguinalhernia. A nephrostogram and subsequent surgeryconfirmed herniation of a loop of transplant ureterinto the inguinal canal with a proximal dilated ureterand hydronephrosis. A long and redundant ureterhad been anastomosed “over” the spermatic cord tothe bladder during the original operation. The ureterwas shortened by excising the distal segment, andthe proximal dilated ureter was anastomosed to thebladder passing it “underneath” the spermatic cord.We used a Vicryl (polyglactin 910) mesh to repair thehernia. The graft function improved to baseline levelsafter the nephrostomy and remained stable after thesurgery.

This case emphasizes the need to keep the uretershort, and the importance of passing it underneaththe spermatic cord before anastomosing to thebladder. Transplant and general surgeons should be

aware of such presentations of graft dysfunction withinguinal hernia to avoid delayed diagnosis and graftloss.

Key words: Kidney transplant, Hydronephrosis, Graftdysfunction

Introduction

Renal transplant is the optimal treatment for end-stage renal disease. Surgical techniques for renaltransplant are well established, and the procedure isassociated with low complication rates whencompared with other abdominal organ transplants.Ureteric implant techniques vary among transplantcenters and among transplant surgeons.1 Mostsurgeons will shorten a redundant ureter before ananastomosis for it to take a direct course to thebladder, which avoids the risk of kinking andischemic strictures. In men, transplant ureters arepassed under the spermatic cord (“water underneaththe bridge”) before anastomosing it to the bladder.The latter avoids kinking and obstruction because ofa taut spermatic cord.2

Inguinal herniation of the transplant ureter is rareafter a renal transplant and there is a paucity ofreports in the literature.3-11 Most often, the allograft islost because of delayed presentation and chronicureteric obstruction. Here, we discuss a case ofinguinal herniation of a transplant ureter to learnfrom this case and avoid future complications.

Case Report

A 72-year-old man presented with progressive graftdysfunction and a symptomatic right inguinal hernia9 years after undergoing a renal transplant. He hadreceived a deceased-donor renal transplant (donationafter brain death) for end-stage renal disease

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From the 1Department of Transplantation, Division of Surgery; and the 2Department of Radiology,St James’s University Hospital NHS Trust, Leeds, LS9 7TF, United KingdomAcknowledgements: The authors declare that they have no sources of funding for this study,and they have no conflicts of interest to declare. Abdul R. Hakeem, Palanivel Gopalakrishnan,and Mohantha D. Dooldeniya prepared the manuscript and collected the images. Henry C. Irvingand Niaz Ahmad corrected the manuscript and agreed with the final draft. Corresponding author: Niaz Ahmad, MD, FRCS, Department of Transplantation, St James’sUniversity Hospital NHS Trust, Beckett Street, Leeds, LS9 7TF, United KingdomPhone: +44 113 206 5175 Fax: +44 113 244 8182 E-mail: niaz.ahmad@leedsth.nhs.uk

Experimental and Clinical Transplantation (2016) 1: 103-105

DOI: 10.6002/ect.2014.0082

Abdul R. Hakeem et al/Experimental and Clinical Transplantation (2016) 1: 103-105 Exp Clin Transplant104

secondary to IgA nephropathy. The graft wasimplanted extraperitoneally through a Gibsonincision in the right iliac fossa. There were a singlerenal artery and a vein, which were implanted on theexternal iliac vessels. The ureter was implanted onlayto the bladder over double J stent. The patient hadstable renal functions and was given immuno-suppression with cyclosporine and azathioprine.

He presented with progressive groin swelling,which caused pain and discomfort of 6 months’duration. At presentation, the hernia was completelyreducible. The patient wanted surgical repair for thehernia and on preoperative screening, we noted thathis serum creatinine concentration had risen from thebaseline of 150 to 160 μmol/L to 304 μmol/L. Sixmonths before presenting, the patient had undergonea transperitoneal laparoscopic radical left nativenephrectomy for a renal cell cancer (PT1a, N0, M0,Fuhrman grade 3). Otherwise, there was no relevantsocial or familial history linked to this presentation.

An ultrasound scan of the transplant kidneyshowed hydronephrosis with a dilated pelvicalicealsystem and proximal ureter. An urgent percutaneousnephrostomy was done, and the serum creatinineconcentration returned to its baseline level. Anantegrade nephrostogram confirmed hydronephrosiswith a grossly dilated proximal ureter, which loopedback onto itself, protruding down into the rightinguinal canal (Figure 1). The distal ureter was ofsmooth caliber, with no focal obstructing lesions;contrast medium passed into the bladder (Figure 1).

The patient underwent elective surgicalexploration via the previous transplant incision, sowe could view the simultaneous reconstruction ofthe ureter and repair of hernia. The inguinal herniacontained grossly distended transplant ureter loopedback onto itself (Figure 2). This was traced distallyover the spermatic cord, to the nondilated lowerureter; it was evident that a long redundant ureterhad been anastomosed to the bladder over thespermatic cord when the original transplant hadbeen done (Figure 3A). The ureter was shortened byexcising the distal segment, and the proximal dilatedureter was anastomosed to the bladder by passing itunderneath the spermatic cord using an onlaytechnique over a double J stent (Figure 3B). We useda Vicryl (polyglactin 910) mesh (Ethicon, WestSomerville, NJ, USA) to repair the hernia.

The patient's serum creatinine concentrationreturned to baseline levels within a few days

after nephrostomy, where it remained stable post-operatively.

Figure 1. Nephrostogram Showing Hydronephrosis and a Dilated ProximalUreter Looping Down Into the Inguinal Canal

Figure 2. An Operative Photograph Showing a Dilated Ureter Crossing Overthe Spermatic Cord

Figure 3A. A Schematic Representation of the Ureteric Herniation (theRedundant Ureter Passes Over the Spermatic Cord)Figure 3B. A Schematic Representation of the Ureteric Reconstruction (theUreter Correctly Passes Under the Spermatic Cord)

Abdul R. Hakeem et al/Experimental and Clinical Transplantation (2016) 1: 103-105

Discussion

Transplant ureteric obstruction are mostly due toureteric strictures, can occur in up to 5% of renaltransplants.12 Other causes of ureteric obstruction areureterolithiasis, kink, preexisting pelviuretericobstruction, external compression, and BK virusinfection.13 Inguinal herniation of a transplant ureter israre after a renal transplant and usually is associatedwith implementing a long redundant ureter, as wasthe case in our patient. Additionally, in our patient, theureter had been passed over the spermatic cord, whichmay have led to the obstruction.

Two events prior to presentation may haveprecipitated the hernia and/or the obstruction. Thepatient underwent a transperitoneal laparoscopicprocedure 6 months before the presentation, and theincreased intra-abdominal pressure and exacerbationof weakness of the abdominal musculature may havecontributed to the hernia. The long and redundantureter then herniated into the inguinal canal with asecondary obstruction leading to progressive graftdysfunction. The patient also had symptoms ofurinary outflow obstruction, which may havecontributed to herniation by raising the intra-abdominal pressure. An alternate explanation is thatthe process began by obstructing the ureter becauseof its course over the spermatic cord. The distendedand redundant proximal ureter then took the easiestway into the hernia sac. Transplant uretericherniation after a laparoscopic procedure andureteric obstruction because of its passage over thespermatic cord both have been described.14,15

Irrespective of the actual sequence of events, therewere 2 avoidable factors, which led to thiscomplication: (1) implantation of a long redundantureter, and (2) the course of the ureter in its relationto the spermatic cord. Herniation of the ureterthrough the transplant wound is not uncommon;however, herniation into the inguinal canal is rareand is always associated with implanting a longureter.16 This complication could have been avoidedwith a short direct course of the ureter to the bladderpassing underneath the spermatic cord. Althoughour patient was managed surgically, Pourafkari andassociates3 reported a conservative approach withureteroscopic dilatation and a retrograde catheterinsertion in a surgically unfit patient, therebyrelieving the ureteric obstruction. Their patient diedof cardiac arrest 4 months after the procedure.

Given the current situation with the shortage ofdonor organs, it is imperative that grafts are not lostfrom avoidable factors. The case also underscores theneed for urgent decompression in any case of renalobstruction, so that irreversible damage is avoided tofunctional renal units. Transplant and generalsurgeons must be aware of such presentations ofgraft dysfunction with inguinal hernia, so as to avoiddelayed diagnosis and prevent graft loss.

References

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