Spontaneous bilateral extraperitoneal ureteroinguinal herniation

Abstract

We describe the clinical and imaging findings of a 53-year-old male who presented with recurrent urinary tract infections with bilateral inguinoscrotal swelling, diagnosed as spontaneous bilateral extraperitoneal ureteroinguinal herniation.

A 53-year-old obese gentleman (body mass index: 35.8 kg/m²) with a history of recurrent urinary tract infections and gradually progressive bilateral scrotal swelling since the age of 15 years presented with intermittent right flank pain for 1 year and low-grade fever for 7 days. He had no voiding symptoms. Examination revealed bilateral inguinal hernia and benign prostatomegaly.

Ultrasonography showed bilateral hydroureteronephrosis (HDUN) with right infected hydronephrosis. Right percutaneous nephrostomy was placed in view of fever, raised leukocyte counts (14,300/mm³), and serum creatinine (1.8 mg/dl). The fever subsided, and serum creatinine became normal (1 mg/dl). A contrast-enhanced computed tomography (CT) showed bilateral nephroptosis with moderate right HDUN and bilateral ureters traversing ipsilateral inguinal canals along with retroperitoneal fat, suggestive of extraperitoneal bilateral ureteroinguinal herniation [Figures 1 and 2]. The patient underwent robot-assisted bilateral hernia repair with mesh placement. One year postoperatively, the patient is doing well.

Figure 1.

Axial computed tomography image showing contrast-filled ureteric loops in respective hemiscrota (white arrows)

Figure 2.

Three-dimensional reconstructed computed tomography image showing the bilateral nephroptotic kidneys with moderate right hydroureteronephrosis and bilateral redundant ureteric loops descending in the ipsilateral inguinal canals suggestive of bilateral ureteroinguinal herniation (white arrows)

Ureteric herniation usually occurs in postrenal transplant setting.[1,2] Bilateral spontaneous ureteric hernias have been rarely reported.[3] Clinicians should suspect this entity in cases of inguinal hernias presenting with urinary complaints/renal impairment and investigate with CT to avoid inadvertent injury to the ureter at the time of repair. Minimally invasive techniques are suitable for bilateral repairs in such obese patients with added advantage of reduced surgical site infections.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.