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Scrotal Incarceration of the Ureter with Crossed Renal Ectopia: Case Report and Literature Review
0022-534 7/89/1422-0366$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1989 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 142, August
Printed in U.S.A.
SCROTAL INCARCERATION OF THE URETER WITH CROSSED RENAL ECTOPIA: CASE REPORT AND LITERATURE REVIEW MARC S. ROCKLIN, KEITH N. APELGREN,* CAROL A. SLOMSKI
AND
STANLEY J. KANDZARI
From the Departments of Surgery, Michigan State University, East Lansing, Michigan, and Department of Urology, West Virginia University, Morgantown, West Virginia
ABSTRACT
To our knowledge only 18 cases of ureteral herniation into the groin have been reported in the literature. We encountered a patient with crossed renal ectopia and ureteral incarceration into a right indirect inguinal hernia. Based on analysis of the presentation and management of our patient combined with a review of the literature we conclude that patients with urinary symptoms and a groin hernia should undergo preoperative urological evaluation, all hernias containing a ureter should be repaired and ureteral resection rarely is necessary during the hernia repair. (J_ Urol., 142: 366-368, 1989) Ureteral herniation has been reported through the sciatic foramen, 1 foramen of Bochdalek, 2 and a crevice between the psoas muscle and iliac vessels. 3 Ureteral herniation into the groin also is a rare event. In 1904 Hartwell reported on a patient whose right inguinal hernia contents included the ureter, cecum, appendix, colon and small intestine, and the patient did not survive. 4 Only 17 cases have been reported subsequently. Our experience with 1 case of ureteral hernia prompted us to review the literature to establish principles of treatment. We analyzed the presentation, hospital course and procedure in a patient with ureteral herniation into a right inguinal hernia.
tolerated the procedure well and was discharged from the hospital 2 days postoperatively. Followup studies 2 months later to evaluate the left kidney included cystoscopy with bilateral retrograde pyelography, which revealed a normal-appearing right kidney with a relatively normal single ureter (fig. 2, A). The left kidney was located ectopically in the right iliac fossa with the ureter crossing over to insert into the normal left trigone (fig. 2, B). Cystoscopy was normal. A renal scan showed good perfusion and tubular function in both kidneys. The patient was last seen in May 1988 with symptoms of prostatism but no groin problems.
CASE REPORT
R. M., a 46-year-old white man, presented in June 1986 with a right scrotal hernia that was nontender but also nonreducible. The hernia had been present for 20 years with gradual enlargement. There were no bowel symptoms but the patient complained of urinary frequency and urgency. Ultrasound revealed a solid mass pushing the right testicle inferiorly. The patient was scheduled for an operation but he did not return. He returned in September 1987 with the complaints of crampy abdominal pain that radiated to the right groin and scrotum, nausea, vomiting, and voiding symptoms of frequency, dysuria and nocturia. Temperature was 40.3C. Physical examination revealed mild tenderness in the right lower quadrant with no peritoneal signs, right scrotal tenderness, a right nonreducible inguinal hernia and a tender prostate. Laboratory evaluation included a white blood count of 21,000 (normal 5,000 to 9,000/mm. 2 ), blood urea nitrogen (BUN) 11 (normal 7 to 20 mg.jdl.), creatinine 1.0 (normal 0.5 to 1.0 mg./dl.), urinalysis 15 to 25 white and 2 to 6 red blood cells and many bacteria, and urine culture yielding greater than 100,000 Klebsiella pneumoniae. An excretory urogram (IVP) revealed right hydronephrosis (fig. 1, A) and a dilated right ureter within the right scrotum (fig. 1, B). The left kidney was not visualized but the left ureter was seen to enter the bladder. The patient improved after receiving intravenous gentamicin. Right inguinal herniorrhaphy was performed the next day via the standard approach. The ureter was surrounded by a 10 X 12 cm. fatty mass and protruded from the internal ring. Neither the peritoneal sac nor the bladder was present and the fat was resected. The ureter was isolated carefully and replaced into the retroperitoneum, after which a Bassini repair was done. The patient Accepted for publication March 1, 1989. *Requests for reprints: Department of Surgery, B424 Clinical Center, East Lansing, Michigan 48824.
DISCUSSION
To our knowledge our patient represents case 19 of ureteral herniation into a femoral or inguinal hernia reported in the literature. 4 - 16 Twelve cases have occurred on the right and 6 on the left sides. Of 16 inguinal hernias 15 occurred in men. Both femoral hernias containing ureter occurred in women. Most patients were in the fourth or fifth decade of life, although a ureter was noted in a right inguinal hernia in a 4-week-old male newborn. 17 A groin mass was the usual presentation. However, urinary symptoms or symptoms of bowel obstruction were noted in 10 patients. Other viscera, including bowel (5 patients), bladder,2 omentum, 1 and uterus and ovaries1 were found in the 19 hernias along with the ureter. The ureter alone was present in 10 of the 19 patients. Evaluation of the 13 most recent patients included an IVP. Only 6 patients had associated renal anomalies, including crossed fused renal ectopia, 3 low lying kidney with double ureter, 1 low lying kidney 1 and multiple renal cysts. 1 We report a case of crossed nonfused renal ectopia. Although it is not clear completely from figure 2, · the renal radionuclide scan done postoperatively revealed nonfusion of the 2 kidneys. Ureteroinguinal hernias may be categorized as paraperitoneal or extraperitoneal. Paraperitoneal hernias occur more frequently (80 per cent) and seem to be acquired. In this type of hernia the ureteral loop is found alongside a peritoneal hernia sac. The pathogenesis is explained best by a nonobliterated peritoneal processus that draws the ureter with it into the inguinal canal and scrotum. This condition occurs either by traction on underlying tissues or as a result of adhesion of the ureter to the posterior wall of the sac. In the less common extraperitoneal type of ureteroinguinal hernia no peritoneal sac is present. This type probably is congenital and due to anomalous development of the ureter from the wolffian duct. Traction on the ureter during testicular 366
SCROTAL INCARCERATION OF URETER WITH CROSSED RENAL ECTOPIA
367
FIG. 1. A, IVP shows right hydronephrosis with herniated ureter over right pubis. B, detail of lower portion of IVP shows dilated right ureter that is herniated. Clinically, herniation was in scrotum rather than in perineum via obturator canal.
FIG. 2. A, retrograde pyelogram demonstrates right ureter and kidney after herniorrhaphy. B, left retrograde pyelogram shows ureter crossing over to ectopic kidney in right flank
descent develops due to persistence of the 2 genitoinguinal ligaments. 1 · 7 An associated hernia of retroperitoneal fat but no sacs occurs secondarily by necessity. 9 • 12 This knowledge becomes important when the surgeon encounters a large amount of fatty tissue and no hernia sac. One should strongly suspect the presence of a ureter in this circumstance, in addition to the vas deferens or round ligament. Peristalsis with stimulation, intravenous injection of indigo carmine or aspiration of urine may aid in identifying the ureter. 12 If the operating surgeon is suspicious of a ureter contained in a hernia, especially if no sac is found, a ureteral injury will be avoided. A preoperative IVP should be considered strongly in a patient with urinary symptoms and a hernia. Although most of these studies will be normal, the ureter may be noted to protrude outside of the bony pelvis, redundant loops of ureter may be seen, or nephroptosis or renal ectopia may be visualized in some cases. Pollack and associates summarized the radiological findings with ureter al herniation." Of the patients with ureter al hernias who underwent an IVP 46 per cent had renal anomalies. Crossed fused renal ectopia and nephroptosis were encountered most frequently. With extraperitoneal ureteral hernias a malpositioned low lying kidney may be a frequent associated congenital anomaly. Periureteral adhesions may lead to hydroureter, hydronephrosis and loss of renal function. The ureter may become strangulated with either type of hernia, and with the paraperitoneal type associated viscera in the hernia sac may become strangulated. In most cases the ureter simply may be placed back into the retroperitoneum. Resection of a portion of the ureter for injury, redundancy or other pathological condition should be necessary only rarely. Only 5 of these 19 patients required such resection.
Inguinal hernias containing ureter nearly always are indirect. Ureterofemoral hernias occur rarely, usually in women. A conventional hernia repair usually is adequate. Recurrences have not been reported. It is clear that any patient with a ureteral groin hernia, whether symptomatic or discovered on an IVP, should undergo surgical correction of the hernia with reduction of the ureter. Based on a review of the management of our case and the literature we conclude that patients with urinary symptoms and a groin hernia should undergo a preoperative IVP. Cystoscopy may or may not be necessary. If a renal anomaly is discovered along with the uretera! hernia the latter probably is of the extraperitoneal type with no hernia sac. All ureteral hernias in the groin should be repaired. In most cases the ureter simply may be placed back into the retroperitoneum and a standard hernia repair may be performed. REFERENCES 1. Watson, L. F.: Hernia: Anatomy, Etiology, Symptoms, Diagnosis,
2. 3. 4. 5. 6. 7.
Differential Diagnosis, Prognosis and Treatment, 2nd ed. St. Louis: The C. V. Mosby Co., p. 532, 1938. Swithinbank, A.H.: Intrathoracic deviation of a ureteric loop. Brit. J. Surg., 45: 379, 1958. Page, B. M.: Obstruction of ureter in internal hernia. Brit. J. Urol., 27: 254, 1955. Hartwell, H.: Ureter in an inguinal hernia. Ann. Surg., 39: 1017, 1904. Ross, G. G. and Taylor, K. P.A.: Sliding hernia of the ureter. Ann. Surg., 73: 613, 1921. Moschcowitz, A. V.: Hernia of the ureter. Ann. Surg., 96: 575, 1932. Dourmashkin, R. L.: Scrotal hernia of ureter, associated with a
368
ROCKLIN AND ASSOCIATES
unilateral fused kidney. A case report. J. Urol., 38: 455, 1937. 8. Jewett, H. J. and Harris, A. P.: Scrotal ureter: report of a case. J. Urol., 69: 184, 1953. 9. Fotopoulos, J.P. and Burkhead, H. C.: Herniation of the ureter. A review and report of a case. Arch. Surg., 82: 290, 1961. 10. Bondevik, H.: Inguinal prolapse of retroperitoneal fat (fatty hernia). A review and report of a case also involving the ureter. Acta Chir. Scand., 131: 492, 1966. 11. Barquin, 0. P. and Madsen, P. 0.: Scrotal herniation of the lower urinary tract. J. Urol., 98: 508, 1967. 12. Tripathi, V. N. and Flint, L. D.: Ureteral herniation. Ann. Surg., 169: 417, 1969.
13. Mallouh, C. and Pellmann, C. M.: Scrotal herniation of the ureter. J. Urol., 106: 38, 1971. 14. Ney, C., Miller, H. L. and Gordimer, H.: Preinguinal canal herniation of the ureter. Value of the curlicue sign direction. Arch. Surg., 105: 633, 1972. 15. Pollack, H. M., Popky, G. L. and Blumberg, M. L.: Hernias of the ureter-an anatomic-roentgenographic study. Radiology, 117: 275, 1975. 16. Percival, W. L.: Ureter within a sliding inguinal hernia. Canad. J. Surg., 26: 283, 1983. 17. Powell, M. C. and Kapila, L.: Bilateral megaureters presenting as an inguinal hernia. J. Ped. Surg., 20: 175, 1985.
Vol. 142, August
Printed in U.S.A.
SCROTAL INCARCERATION OF THE URETER WITH CROSSED RENAL ECTOPIA: CASE REPORT AND LITERATURE REVIEW MARC S. ROCKLIN, KEITH N. APELGREN,* CAROL A. SLOMSKI
AND
STANLEY J. KANDZARI
From the Departments of Surgery, Michigan State University, East Lansing, Michigan, and Department of Urology, West Virginia University, Morgantown, West Virginia
ABSTRACT
To our knowledge only 18 cases of ureteral herniation into the groin have been reported in the literature. We encountered a patient with crossed renal ectopia and ureteral incarceration into a right indirect inguinal hernia. Based on analysis of the presentation and management of our patient combined with a review of the literature we conclude that patients with urinary symptoms and a groin hernia should undergo preoperative urological evaluation, all hernias containing a ureter should be repaired and ureteral resection rarely is necessary during the hernia repair. (J_ Urol., 142: 366-368, 1989) Ureteral herniation has been reported through the sciatic foramen, 1 foramen of Bochdalek, 2 and a crevice between the psoas muscle and iliac vessels. 3 Ureteral herniation into the groin also is a rare event. In 1904 Hartwell reported on a patient whose right inguinal hernia contents included the ureter, cecum, appendix, colon and small intestine, and the patient did not survive. 4 Only 17 cases have been reported subsequently. Our experience with 1 case of ureteral hernia prompted us to review the literature to establish principles of treatment. We analyzed the presentation, hospital course and procedure in a patient with ureteral herniation into a right inguinal hernia.
tolerated the procedure well and was discharged from the hospital 2 days postoperatively. Followup studies 2 months later to evaluate the left kidney included cystoscopy with bilateral retrograde pyelography, which revealed a normal-appearing right kidney with a relatively normal single ureter (fig. 2, A). The left kidney was located ectopically in the right iliac fossa with the ureter crossing over to insert into the normal left trigone (fig. 2, B). Cystoscopy was normal. A renal scan showed good perfusion and tubular function in both kidneys. The patient was last seen in May 1988 with symptoms of prostatism but no groin problems.
CASE REPORT
R. M., a 46-year-old white man, presented in June 1986 with a right scrotal hernia that was nontender but also nonreducible. The hernia had been present for 20 years with gradual enlargement. There were no bowel symptoms but the patient complained of urinary frequency and urgency. Ultrasound revealed a solid mass pushing the right testicle inferiorly. The patient was scheduled for an operation but he did not return. He returned in September 1987 with the complaints of crampy abdominal pain that radiated to the right groin and scrotum, nausea, vomiting, and voiding symptoms of frequency, dysuria and nocturia. Temperature was 40.3C. Physical examination revealed mild tenderness in the right lower quadrant with no peritoneal signs, right scrotal tenderness, a right nonreducible inguinal hernia and a tender prostate. Laboratory evaluation included a white blood count of 21,000 (normal 5,000 to 9,000/mm. 2 ), blood urea nitrogen (BUN) 11 (normal 7 to 20 mg.jdl.), creatinine 1.0 (normal 0.5 to 1.0 mg./dl.), urinalysis 15 to 25 white and 2 to 6 red blood cells and many bacteria, and urine culture yielding greater than 100,000 Klebsiella pneumoniae. An excretory urogram (IVP) revealed right hydronephrosis (fig. 1, A) and a dilated right ureter within the right scrotum (fig. 1, B). The left kidney was not visualized but the left ureter was seen to enter the bladder. The patient improved after receiving intravenous gentamicin. Right inguinal herniorrhaphy was performed the next day via the standard approach. The ureter was surrounded by a 10 X 12 cm. fatty mass and protruded from the internal ring. Neither the peritoneal sac nor the bladder was present and the fat was resected. The ureter was isolated carefully and replaced into the retroperitoneum, after which a Bassini repair was done. The patient Accepted for publication March 1, 1989. *Requests for reprints: Department of Surgery, B424 Clinical Center, East Lansing, Michigan 48824.
DISCUSSION
To our knowledge our patient represents case 19 of ureteral herniation into a femoral or inguinal hernia reported in the literature. 4 - 16 Twelve cases have occurred on the right and 6 on the left sides. Of 16 inguinal hernias 15 occurred in men. Both femoral hernias containing ureter occurred in women. Most patients were in the fourth or fifth decade of life, although a ureter was noted in a right inguinal hernia in a 4-week-old male newborn. 17 A groin mass was the usual presentation. However, urinary symptoms or symptoms of bowel obstruction were noted in 10 patients. Other viscera, including bowel (5 patients), bladder,2 omentum, 1 and uterus and ovaries1 were found in the 19 hernias along with the ureter. The ureter alone was present in 10 of the 19 patients. Evaluation of the 13 most recent patients included an IVP. Only 6 patients had associated renal anomalies, including crossed fused renal ectopia, 3 low lying kidney with double ureter, 1 low lying kidney 1 and multiple renal cysts. 1 We report a case of crossed nonfused renal ectopia. Although it is not clear completely from figure 2, · the renal radionuclide scan done postoperatively revealed nonfusion of the 2 kidneys. Ureteroinguinal hernias may be categorized as paraperitoneal or extraperitoneal. Paraperitoneal hernias occur more frequently (80 per cent) and seem to be acquired. In this type of hernia the ureteral loop is found alongside a peritoneal hernia sac. The pathogenesis is explained best by a nonobliterated peritoneal processus that draws the ureter with it into the inguinal canal and scrotum. This condition occurs either by traction on underlying tissues or as a result of adhesion of the ureter to the posterior wall of the sac. In the less common extraperitoneal type of ureteroinguinal hernia no peritoneal sac is present. This type probably is congenital and due to anomalous development of the ureter from the wolffian duct. Traction on the ureter during testicular 366
SCROTAL INCARCERATION OF URETER WITH CROSSED RENAL ECTOPIA
367
FIG. 1. A, IVP shows right hydronephrosis with herniated ureter over right pubis. B, detail of lower portion of IVP shows dilated right ureter that is herniated. Clinically, herniation was in scrotum rather than in perineum via obturator canal.
FIG. 2. A, retrograde pyelogram demonstrates right ureter and kidney after herniorrhaphy. B, left retrograde pyelogram shows ureter crossing over to ectopic kidney in right flank
descent develops due to persistence of the 2 genitoinguinal ligaments. 1 · 7 An associated hernia of retroperitoneal fat but no sacs occurs secondarily by necessity. 9 • 12 This knowledge becomes important when the surgeon encounters a large amount of fatty tissue and no hernia sac. One should strongly suspect the presence of a ureter in this circumstance, in addition to the vas deferens or round ligament. Peristalsis with stimulation, intravenous injection of indigo carmine or aspiration of urine may aid in identifying the ureter. 12 If the operating surgeon is suspicious of a ureter contained in a hernia, especially if no sac is found, a ureteral injury will be avoided. A preoperative IVP should be considered strongly in a patient with urinary symptoms and a hernia. Although most of these studies will be normal, the ureter may be noted to protrude outside of the bony pelvis, redundant loops of ureter may be seen, or nephroptosis or renal ectopia may be visualized in some cases. Pollack and associates summarized the radiological findings with ureter al herniation." Of the patients with ureter al hernias who underwent an IVP 46 per cent had renal anomalies. Crossed fused renal ectopia and nephroptosis were encountered most frequently. With extraperitoneal ureteral hernias a malpositioned low lying kidney may be a frequent associated congenital anomaly. Periureteral adhesions may lead to hydroureter, hydronephrosis and loss of renal function. The ureter may become strangulated with either type of hernia, and with the paraperitoneal type associated viscera in the hernia sac may become strangulated. In most cases the ureter simply may be placed back into the retroperitoneum. Resection of a portion of the ureter for injury, redundancy or other pathological condition should be necessary only rarely. Only 5 of these 19 patients required such resection.
Inguinal hernias containing ureter nearly always are indirect. Ureterofemoral hernias occur rarely, usually in women. A conventional hernia repair usually is adequate. Recurrences have not been reported. It is clear that any patient with a ureteral groin hernia, whether symptomatic or discovered on an IVP, should undergo surgical correction of the hernia with reduction of the ureter. Based on a review of the management of our case and the literature we conclude that patients with urinary symptoms and a groin hernia should undergo a preoperative IVP. Cystoscopy may or may not be necessary. If a renal anomaly is discovered along with the uretera! hernia the latter probably is of the extraperitoneal type with no hernia sac. All ureteral hernias in the groin should be repaired. In most cases the ureter simply may be placed back into the retroperitoneum and a standard hernia repair may be performed. REFERENCES 1. Watson, L. F.: Hernia: Anatomy, Etiology, Symptoms, Diagnosis,
2. 3. 4. 5. 6. 7.
Differential Diagnosis, Prognosis and Treatment, 2nd ed. St. Louis: The C. V. Mosby Co., p. 532, 1938. Swithinbank, A.H.: Intrathoracic deviation of a ureteric loop. Brit. J. Surg., 45: 379, 1958. Page, B. M.: Obstruction of ureter in internal hernia. Brit. J. Urol., 27: 254, 1955. Hartwell, H.: Ureter in an inguinal hernia. Ann. Surg., 39: 1017, 1904. Ross, G. G. and Taylor, K. P.A.: Sliding hernia of the ureter. Ann. Surg., 73: 613, 1921. Moschcowitz, A. V.: Hernia of the ureter. Ann. Surg., 96: 575, 1932. Dourmashkin, R. L.: Scrotal hernia of ureter, associated with a
368
ROCKLIN AND ASSOCIATES
unilateral fused kidney. A case report. J. Urol., 38: 455, 1937. 8. Jewett, H. J. and Harris, A. P.: Scrotal ureter: report of a case. J. Urol., 69: 184, 1953. 9. Fotopoulos, J.P. and Burkhead, H. C.: Herniation of the ureter. A review and report of a case. Arch. Surg., 82: 290, 1961. 10. Bondevik, H.: Inguinal prolapse of retroperitoneal fat (fatty hernia). A review and report of a case also involving the ureter. Acta Chir. Scand., 131: 492, 1966. 11. Barquin, 0. P. and Madsen, P. 0.: Scrotal herniation of the lower urinary tract. J. Urol., 98: 508, 1967. 12. Tripathi, V. N. and Flint, L. D.: Ureteral herniation. Ann. Surg., 169: 417, 1969.
13. Mallouh, C. and Pellmann, C. M.: Scrotal herniation of the ureter. J. Urol., 106: 38, 1971. 14. Ney, C., Miller, H. L. and Gordimer, H.: Preinguinal canal herniation of the ureter. Value of the curlicue sign direction. Arch. Surg., 105: 633, 1972. 15. Pollack, H. M., Popky, G. L. and Blumberg, M. L.: Hernias of the ureter-an anatomic-roentgenographic study. Radiology, 117: 275, 1975. 16. Percival, W. L.: Ureter within a sliding inguinal hernia. Canad. J. Surg., 26: 283, 1983. 17. Powell, M. C. and Kapila, L.: Bilateral megaureters presenting as an inguinal hernia. J. Ped. Surg., 20: 175, 1985.