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Acute Renal Failure Caused by Bilateral Ureteral Herniation Through the Sciatic Foramen
Images in Clinical Urology Acute Renal Failure Caused by Bilateral Ureteral Herniation Through the Sciatic Foramen James J. Whyburn and Ahmadreza Alizadeh Ureteral herniation is rare. Only a few cases of bilateral ureterosciatic herniation have been reported. We report the case of a 74-year-old woman with flank pain and acute renal failure. The initial ultrasound scan showed bilateral hydronephrosis. Follow-up computed tomography imaging demonstrated sciatic herniation of both ureters, causing bilateral hydronephrosis and hydroureter. The patient underwent bilateral retrograde ureterography and ureteral stent placement, with improvement in renal function to normal limits. Observation after stent removal demonstrated recurrent sciatic herniation of both ureters. Definitive surgical correction was performed by way of laparoscopic bilateral ureterolysis and sciatic notch hernia repair using mesh. UROLOGY 81: e38ee39, 2013. 2013 Elsevier Inc.
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reteral herniation is rare, most commonly occurring in the inguinal canal. Ureteral herniation has been less commonly reported in the femoral, sciatic, thoracic, and parailiac areas.1 The sciatic foramen is the least common site of herniation, with <30 published reports.2 Only a few reports have been published of bilateral ureterosciatic herniation. Herniation typically occurs through the superior portion of the greater sciatic foramen. Ureterosciatic herniation is more common in elderly women and infants. The predisposing factors include defects in the parietal pelvic fascia, atrophy of the piriformis muscle, and hip joint disease. The symptoms are typically nonspecific, with ill-defined abdominal pain until obstructive uropathy develops. The diagnosis can be made radiographically with computed tomography (Fig. 1) or pyelography (Fig. 2). A radiographic “curlicue” sign has been described as the ureter loops through the sciatic foramen4 (Fig. 2). The herniated ureteral segment will be visualized posteriorly and laterally to the ischial spine. Treatment options include observation in asymptomatic patients, surgical repair, and ureteral stent placement with observation.2 Placement of ureteral stents alone is unlikely to provide permanent correction.2 Definitive surgical correction would include a combination of hernia repair and ureteral resection or reimplantation.3,5 Previously, open surgery was performed, although, recently, laparoscopic repair has been reported.3,5 References 1. Rommel FM, Boline GB, Huffnagle HW. Ureterosciatic hernia: an anatomical radiographic correlation. J Urol. 1993;150:12321233.
Figure 1. Computed tomography scan demonstrating bilateral ureteral herniation through sciatic foramen with proximal hydroureter.
2. Loffroy R, Bry J, Guiu B, et al. Ureterosciatic hernia: a rare cause of ureteral obstruction visualized by multislice helical computed tomography. Urology. 2007;69:385.e1-385.e3. 3. Whitney-Smith C, Undre S, Salter V, Al-Akraa M. An unusual case of ureteric hernia into the sciatic foramen causing urinary sepsis: successfully treated laparoscopically. Ann R Coll Surg Engl. 2007;89: W10-W12. 4. Beck WC, Baurys W, Brochu J, et al. Herniation of ureter into the sciatic foramen (“curlicue ureter”). JAMA. 1952;149:441-442. 5. Speeg J, Vanlangendonck R, Fusilier H, Richardson W. An unusual presentation of a sciatic hernia. Am Surg. 2009;75:1139-1141.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Radiology, Lenox Hill Hospital, New York, NY Reprint requests: James J. Whyburn, M.D., Department of Urology, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10075. E-mail: [email protected] Submitted: November 6, 2012, accepted (with revisions): February 26, 2013
e38
ª 2013 Elsevier Inc. All Rights Reserved
0090-4295/13/$36.00 http://dx.doi.org/10.1016/j.urology.2013.02.047
Figure 2. Ureteroscopy of both ureters demonstrating “curlicue” sign as ureter loops through sciatic foramen.
UROLOGY 81 (6), 2013
e39
U
reteral herniation is rare, most commonly occurring in the inguinal canal. Ureteral herniation has been less commonly reported in the femoral, sciatic, thoracic, and parailiac areas.1 The sciatic foramen is the least common site of herniation, with <30 published reports.2 Only a few reports have been published of bilateral ureterosciatic herniation. Herniation typically occurs through the superior portion of the greater sciatic foramen. Ureterosciatic herniation is more common in elderly women and infants. The predisposing factors include defects in the parietal pelvic fascia, atrophy of the piriformis muscle, and hip joint disease. The symptoms are typically nonspecific, with ill-defined abdominal pain until obstructive uropathy develops. The diagnosis can be made radiographically with computed tomography (Fig. 1) or pyelography (Fig. 2). A radiographic “curlicue” sign has been described as the ureter loops through the sciatic foramen4 (Fig. 2). The herniated ureteral segment will be visualized posteriorly and laterally to the ischial spine. Treatment options include observation in asymptomatic patients, surgical repair, and ureteral stent placement with observation.2 Placement of ureteral stents alone is unlikely to provide permanent correction.2 Definitive surgical correction would include a combination of hernia repair and ureteral resection or reimplantation.3,5 Previously, open surgery was performed, although, recently, laparoscopic repair has been reported.3,5 References 1. Rommel FM, Boline GB, Huffnagle HW. Ureterosciatic hernia: an anatomical radiographic correlation. J Urol. 1993;150:12321233.
Figure 1. Computed tomography scan demonstrating bilateral ureteral herniation through sciatic foramen with proximal hydroureter.
2. Loffroy R, Bry J, Guiu B, et al. Ureterosciatic hernia: a rare cause of ureteral obstruction visualized by multislice helical computed tomography. Urology. 2007;69:385.e1-385.e3. 3. Whitney-Smith C, Undre S, Salter V, Al-Akraa M. An unusual case of ureteric hernia into the sciatic foramen causing urinary sepsis: successfully treated laparoscopically. Ann R Coll Surg Engl. 2007;89: W10-W12. 4. Beck WC, Baurys W, Brochu J, et al. Herniation of ureter into the sciatic foramen (“curlicue ureter”). JAMA. 1952;149:441-442. 5. Speeg J, Vanlangendonck R, Fusilier H, Richardson W. An unusual presentation of a sciatic hernia. Am Surg. 2009;75:1139-1141.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Radiology, Lenox Hill Hospital, New York, NY Reprint requests: James J. Whyburn, M.D., Department of Urology, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10075. E-mail: [email protected] Submitted: November 6, 2012, accepted (with revisions): February 26, 2013
e38
ª 2013 Elsevier Inc. All Rights Reserved
0090-4295/13/$36.00 http://dx.doi.org/10.1016/j.urology.2013.02.047
Figure 2. Ureteroscopy of both ureters demonstrating “curlicue” sign as ureter loops through sciatic foramen.
UROLOGY 81 (6), 2013
e39