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Hydronephrosis Caused by Ureterosciatic Herniation
Images in Clinical Urology Hydronephrosis Caused by Ureterosciatic Herniation Huan-Lun Hsu, Kuo-How Huang, Chin-Chen Chang, and Kao-Lang Liu A 69-year-old woman with history of operation for stress urinary incontinence presented with left flank soreness. Physical examination revealed knocking tenderness at left costal-vertebral angle. Her serum creatinine level was 1.2 mg/dL and urine analysis was negative. Ultrasonography showed left hydronephrosis, and computed tomography scan revealed ureterosciatic herniation. An antegrade placement of the indwelling ureteral stent was performed. After 3 months, the double J catheter was removed and the patient recovered without recurrent symptoms. UROLOGY 76: 1375–1376, 2010. © 2010 Elsevier Inc.
Figure 2. Nonenhanced computed tomography scan immediately after intravenous urography study. The computed tomography urography showed the left ureter was herniated into the left sciatic foramen (arrows). Also noted are the weakness and atrophy of the left piriformis muscle.
Figure 1. Intravenous urography. At 10 minutes, bilateral renal nephrograms were shown with smooth contours but the left ureter was not opacified.
A
69-year-old woman with the history of stress urinary incontinence underwent tension-free vaginal tape suspension and showed improvement. Left flank soreness developed 1 month later. Physical examination revealed knocking tenderness at left costal-vertebral angle. Her serum creatinine level was 1.2 From the Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan; Department of Urology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; and Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan Reprint requests: Kao-Lang Liu, M.D., Department of Medical Imaging, National Taiwan University Hospital, 7, Chung-Shan S Rd, Taipei, Taiwan. E-mail: lkl@ntu. edu.tw Submitted: October 28, 2009, accepted (with revisions): December 18, 2009
© 2010 Elsevier Inc. All Rights Reserved
mg/dL and urine analysis was negative. Ultrasonography showed nonspecific findings of both kidneys before surgery. However, left hydronephrosis was revealed by ultrasonography and the left ureter was not shown by intravenous urography (IVU) (Fig. 1). The immediate nonenhanced computed tomography scan after IVU showed the sciatic herniation of the left distal ureter, which was herniated into inferior posterior location of the ischial spine, because of the weakness and atrophy of the left piriformis muscle (Fig. 2). Percutaneous nephrostomy disclosed the obstructive level at the distal ureter with a U-shaped tortuosity (Fig. 3). An antegrade placement of the indwelling ureteral stent was performed. After 3 months, the double-J catheter was removed and the patient was recovered without recurrent symptoms, at least 6-month duration after stent removal. Ureterosciatic herniation is an uncommon disease and the predisposing factors are defect in the parietal pelvic fascia, piriformis muscle atrophy, adhesions, or congeni0090-4295/10/$36.00 doi:10.1016/j.urology.2009.12.039
1375
tal anomalies.1-4 Both IVU study and computed tomography scan may help diagnosis preoperatively. The choice of treatment include fixation of the ureter with surgery and placement of an indwelling stent.1
References 1. Weintraub JL, Pappas GM, Romano WJ, et al. Percutaneous reduction of ureterosciatic hernia. AJR Am J Roentgenol. 2000;175:181182. 2. Tsai PJ, Lin JT, Wu TT, et al. Ureterosciatic hernia causes obstructive uropathy. J Chin Med Assoc. 2008;71:491-493. 3. 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-e3. 4. Touloupidis S, Kalaitzis C, Schneider A, et al. Ureterosciatic hernia with compression of the sciatic nerve. Int Urol Nephrol. 2006;38: 457-458.
Figure 3. Percutaneous nephrostomy with double J catheter placement. The course of the left ureterosciatic hernia was delineated by the antegrade guidewire insertion in the prone position.
1376
UROLOGY 76 (6), 2010
Figure 2. Nonenhanced computed tomography scan immediately after intravenous urography study. The computed tomography urography showed the left ureter was herniated into the left sciatic foramen (arrows). Also noted are the weakness and atrophy of the left piriformis muscle.
Figure 1. Intravenous urography. At 10 minutes, bilateral renal nephrograms were shown with smooth contours but the left ureter was not opacified.
A
69-year-old woman with the history of stress urinary incontinence underwent tension-free vaginal tape suspension and showed improvement. Left flank soreness developed 1 month later. Physical examination revealed knocking tenderness at left costal-vertebral angle. Her serum creatinine level was 1.2 From the Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan; Department of Urology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; and Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan Reprint requests: Kao-Lang Liu, M.D., Department of Medical Imaging, National Taiwan University Hospital, 7, Chung-Shan S Rd, Taipei, Taiwan. E-mail: lkl@ntu. edu.tw Submitted: October 28, 2009, accepted (with revisions): December 18, 2009
© 2010 Elsevier Inc. All Rights Reserved
mg/dL and urine analysis was negative. Ultrasonography showed nonspecific findings of both kidneys before surgery. However, left hydronephrosis was revealed by ultrasonography and the left ureter was not shown by intravenous urography (IVU) (Fig. 1). The immediate nonenhanced computed tomography scan after IVU showed the sciatic herniation of the left distal ureter, which was herniated into inferior posterior location of the ischial spine, because of the weakness and atrophy of the left piriformis muscle (Fig. 2). Percutaneous nephrostomy disclosed the obstructive level at the distal ureter with a U-shaped tortuosity (Fig. 3). An antegrade placement of the indwelling ureteral stent was performed. After 3 months, the double-J catheter was removed and the patient was recovered without recurrent symptoms, at least 6-month duration after stent removal. Ureterosciatic herniation is an uncommon disease and the predisposing factors are defect in the parietal pelvic fascia, piriformis muscle atrophy, adhesions, or congeni0090-4295/10/$36.00 doi:10.1016/j.urology.2009.12.039
1375
tal anomalies.1-4 Both IVU study and computed tomography scan may help diagnosis preoperatively. The choice of treatment include fixation of the ureter with surgery and placement of an indwelling stent.1
References 1. Weintraub JL, Pappas GM, Romano WJ, et al. Percutaneous reduction of ureterosciatic hernia. AJR Am J Roentgenol. 2000;175:181182. 2. Tsai PJ, Lin JT, Wu TT, et al. Ureterosciatic hernia causes obstructive uropathy. J Chin Med Assoc. 2008;71:491-493. 3. 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-e3. 4. Touloupidis S, Kalaitzis C, Schneider A, et al. Ureterosciatic hernia with compression of the sciatic nerve. Int Urol Nephrol. 2006;38: 457-458.
Figure 3. Percutaneous nephrostomy with double J catheter placement. The course of the left ureterosciatic hernia was delineated by the antegrade guidewire insertion in the prone position.
1376
UROLOGY 76 (6), 2010