Giant megaureter presenting as femoral hernia: case report

Abstract

Introduction and importance:

A mega ureter is an abnormally dilated ureter. It is one of the common ureteral anomalies. It manifests in various forms, ranging from incidental findings to obstructive uropathy. A megaureter herniating through the femoral canal is unreported. If the diagnosis is missed, the herniated ureter can be inadvertently injured. Management of a megaureter depends on the clinical condition of the patient.

Case presentation:

A 30-year-old female patient presented with progressive abdominal swelling, which extended to the left mid-thigh. She was operated on and found to have a hugely dilated ureter, which is herniated through the femoral canal, and she underwent a left ureteronephrectomy since the kidney was an atrophied, hydronephrotic kidney.

Clinical discussion:

A megaureter is a common ureteral anomaly caused by different mechanisms. It is usually asymptomatic, but can present as recurrent urinary tract infection, abdominal pain and flank pain. Rarely present as abdominal/flank pain and urinary incontinence. Presentation as an inguinal hernia is extremely rare, and a megaureter herniating through the femoral canal is not reported in the English literature. Diagnosis of mega ureter involves clinical evaluation and radiologic imaging. Its management depends on the type of mega ureter, clinical condition of the patient and renal status.

Conclusion:

Even though it is rare, a herniated ureter should be considered in the differential diagnosis of an irreducible inguinal mass. Diagnosis can be established through imaging such as ultrasonography or CT urography. Early recognition is crucial, as careful surgical repair with identification and preservation of the ureter prevents inadvertent injury and preserves renal function.

Introduction

Megaureter is one of the common ureteral anomalies^[1,2]. It is classified as the obstructive, refluxing, obstructive–refluxive and non-obstructive–non-refluxing megaureter^[2,3]. It has a wide range of presentations which can be detected incidentally to features of obstructive uropathy^[4,5]. A herniated megaureter is an extremely rare presentation^[6]. The type of management for megaureter depends on the underlying causes, presence of urinary tract infection and renal status^[7,8]. The work has been reported in line with the SCARE criteria^[9].

HIGHLIGHTS

• Megaureter is one of the common ureteral anomalies

• Herniated megaureter presented as inguinal mass is an extremely rare presentation

• The type of management for megaureter depends on different factors

Case presentation

A 30-year-old black African female patient presented with progressive abdominal swelling of 5-year duration, which worsened over the past 1 year. It was initially slowly growing over the first 4 years, but increased rapidly over the last 1 year. The swelling initially began on the left side of the abdomen and progressively involved the entire abdomen and the left inguinal area. She has dull-type abdominal pain, easy fatigability, early satiety and left lower limb limping. Otherwise, no urinary complaints or bowel habit change. She has regular menses. She didn’t have any previous hospital admission. No history of drug allergy or smoking. On physical examination, vital signs were in the normal range (Blood pressure: 110/70 mm Hg, Pulse rate: 80, Respiratory rate: 18). On abdominal examination, the abdomen was grossly distended. There is about a 20 × 30 cm measuring left side abdominal mass crossing the midline and extending down to the left mid-thigh. She was investigated with urine analysis, complete blood count and renal function test, and all were unremarkable. An abdominal and pelvic ultrasound showed a cystic intra-abdominal mass herniating through the femoral canal; the mass pushed the urinary bladder to the right side. The left kidney is hydro nephrotic and atrophied. The contralateral kidney appeared to be normal. On a computer tomogram (CT) scan, there was a huge intra-abdominal cystic mass crossing midline and displacing the bowel and urinary bladder to the right side (Fig. 1A), extending down to the mid-thigh. Atrophied hydro nephrotic left kidney (Fig. 1A). Contra contralateral kidney appeared normal (Fig. 1C). Cystoscopy was done and showed normal bladder mucosa with normal appearing ureteric orifices, but the bladder was slightly pushed to the right side. The patient was counselled, and after written informed consent, she underwent an exploratory laparotomy through a midline vertical incision. Intraoperatively, there was an atrophied hydro nephrotic left kidney (bag of urine) with a hugely dilated ureter, which displaced the bowel to the right side, and its distal one-third, before insertion into the urinary bladder, was herniated through the femoral canal and reached the level of mid-thigh (Fig. 2). The ureter was reduced from the femoral canal after the abdomen was entered. Since there was no appreciable left renal parenchyma, left uretero nephrectomy was done. Tissue repair for the hernia defect was done trans abdominally. There was no intraoperative complication. The patient was discharged home on the second postoperative day. She had a smooth postoperative course at 6 months follow-up with normal renal function test, healed surgical wound and complete symptom resolution. No histopathological report is presented because there was no intraoperative confusion.

Figure 1.

CT scan showing a huge cystic intra-abdominal mass displacing bowel and urinary bladder to the right side (A; white arrow marking urinary bladder) and the mass extending down to the left mid-thigh (B; white arrow) with an atrophied hydronephrotic kidney (B; black arrow). Normal appearing right kidney (C; blue arrow).

Figure 2.

Intraoperative images. Grossly distended abdomen with the inguinal swelling extending down to the left mid-thigh (marked with broken line; A). Intraoperative image showing dilated ureter after decompression (B) with femoral canal defect after uretero-nephrectomy (C).

Discussion

Urinary tract anomalies are the most common congenital anomaly in the human body^[1,2]. Mega ureter is a type of ureteral anomaly characterized by abnormal dilatation of the ureter. It can be classified as the obstructive, refluxing, non-obstructive-refluxing and non-obstructive-non-refluxing megaureter^[2,3]. An obstructive mega ureter is characterized by abnormal dilatation of the ureter due to an obstruction that interferes with the normal flow of urine. The common site of obstruction in the megaureter is at the ureterovesical junction. This condition can be congenital or acquired. Congenital obstructive megaureter is usually caused by the intrinsic distal ureteral anomaly and rarely ectopic ureter. The acquired type is uncommon and can be caused by a distal ureteral stone, pelvic fibrosis encasing the distal ureter and tumor growing from pelvic organs^[4,5,10]. If left untreated, the obstructive megaureter can lead to hydronephrosis and renal damage due to increased pressure in the urinary system^[2,5,11].

Obstructive mega ureter has a wide range of presentations. It may be asymptomatic and detected incidentally during imaging for other purposes. If Symptomatic, the common presentations are recurrent urinary tract infection, abdominal pain and flank pain^[4,5]. Other rare presentations are abdominal mass, urinary incontinence and epididymorchitis^[2,7]. Megaureter presenting as an inguinal mass is extremely rare^[6].

The diagnosis of megaureter involves a combination of clinical evaluation and imaging studies. The common imaging modalities used to evaluate megaureter are abdominopelvic ultrasound, cystourethrogram (CUG), intravenous pyelogram (IVP), computed tomography urogram (CTU) and magnetic resonance imaging (MRI). Ultrasonography can diagnose a megaureter, but it is difficult to classify in type. Cystourethrogram is important in detecting urinary reflux, detecting the ureteral orifice and, if there are secondary causes for megaureter. Intravenous pyelogram is important in evaluating the functional status of the kidney, presence and absence of ureteral duplication, site of ureteral orifice and degree of dilatation of the ureter. The drawback of IVP is that it depends on renal function and cannot help if that kidney is not functioning. CTU and MRI are very important imaging modalities that help evaluate the renal function status, degree of ureteral dilatation, site and ureteral orifice and also help to detect pelvic masses causing secondary megaureter^[1,3,7].

The management of obstractive megaureter depends on the degree of hydronephrosis, the kidney’s functional status and the underlying causes of obstractive megaureter^[1,2,4,5]. In an asymptomatic megaureter with mild ureterohydronephrosis and a normal site ureterovesical junction, the patient can be followed with close follow-up. In symptomatic patients, management is surgical intervention involving endoscopic balloon dilatation, ureteral re-implantation or uretero nephrectomy. If the kidney is functional and the cause of the megaureter is the primary cause, management will be ureterovesical re-implantation. If the kidney is nonfunctional, the management will be removing both the kidney and the ipsilateral ureter (ureter nephrectomy)^[11]. For secondary megaureter, managing the underlying cause will suffice for the management and rarely needs ureteral re-reimplantation^{[4,5,7,8,10,11]}.

Conclusion

Even though it is rare, a herniated ureter should be considered in the differential diagnosis of an irreducible inguinal mass. Diagnosis can be established through imaging such as ultrasonography or CT urography. Early recognition is crucial, as careful surgical repair with identification and preservation of the ureter prevents inadvertent injury and preserves renal function.

Ethical approval

Ethical approval is held to be unnecessary by Salale University comprehensive specialized hospital Institutional Review Board as this is a single rare case encountered during clinical practice.

Consent

A written informed consent has been obtained from the patient to have the case details and any accompanying images published. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

No specific grant from funding organizations in the public, private, or nonprofit sectors was given to this manuscript.

Author contributions

A.B.: and D.G.: operated on the patient, wrote the case presentation and also following the patient; T.G.: wrote the final case report. All authors read and approved the final manuscript.

Conflicts of interest disclosure

No authors have disclosed any conflicts of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Tafese Gudissa Merga.