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URETERAL SCIATIC HERNIA DEMONSTRATED ON RETROGRADE UROGRAPHY AND SURGICALLY REPAIRED WITH BOARI FLAP TECHNIQUE
0022-5347/00/1643-0776/0 THE JOURNAL OF UROLOGY® Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 164, 776 –777, September 2000 Printed in U.S.A.
URETERAL SCIATIC HERNIA DEMONSTRATED ON RETROGRADE UROGRAPHY AND SURGICALLY REPAIRED WITH BOARI FLAP TECHNIQUE MARK W. NOLLER
AND
DAVID W. NOLLER
From the United States Army Health Clinic, Schweinfurt, Germany, and A Medical Corporation, San Jose, California KEY WORDS: ureter, hernia, surgical flaps, urography
Ureteral sciatic hernias are rare and their etiology varies. Patients can present with vague and nonspecific symptoms, which makes diagnosis difficult. We report a case of a ureteral sciatic hernia revealed on retrograde urography and repaired with a Boari flap technique. CASE REPORT
A 62-year-old woman was admitted to the hospital with the chief complaints of abdominal pain, nausea and decreased appetite 5 days in duration. Initial vital signs and laboratory tests, including urinalysis, were normal. Excretory urography (IVP) showed significant hydronephrosis and hydroureter from the level of the mid pelvis. Abdominal computerized tomography (CT) revealed obstruction of the distal left ureter with herniation into the sciatic foramen (fig. 1). The patient underwent retrograde ureteroscopy, which revealed acute narrowing and 180-degree tortuosity with posterior deviation behind the acetabulum (fig. 2). Attempted passage of a ureteral catheter would not negotiate the acute tortuosity. Left Gibson and muscle splitting incisions were made retroperitoneally to the dilated left ureter. The left ureter was isolated and dissected down to the sciatic foramen, where the ureter invaginated into the foramen. At this point the ureter was markedly fibrotic, tortuous and angulated at 180 degrees. This segment of ureter was excised and taken down to the ureterovesical junction. The proximal ureter was reimplanted into the bladder using a Boari flap technique (fig. 3). No attempt was made to close the hernia because it was covered with omentum. Convalescence was uneventful and the patient was discharged from the hospital 4 days postoperatively.
FIG. 2. Retrograde ureterogram reveals 180-degree tortuosity of left ureter in sciatic foramen.
DISCUSSION
Sciatic herniation of the ureter is uncommon and difficult to diagnose on physical examination. Sciatic hernias seem to occur more frequently in females due to a larger sciatic foramen and wider pelvis. Other predisposing factors include Accepted for publication April 7, 2000.
FIG. 3. Postoperative IVP demonstrates patency of Boari flap.
neuromuscular disorders causing atrophy of the piriform FIG. 1. CT shows passage of calcified left ureter (arrow) into sci- muscle, hip joint diseases and congenital defects in the pelvic fascia.1 More than 11 cases have been reported.2 atic foramen. 776
777
URETERAL SCIATIC HERNIA
Herniation due to a defect in the parietal pelvic fascia is more common in elderly women.3 Diagnoses has been made on IVP, retrograde urography and CT with the use of 3-dimensional reconstruction.3 More of these cases are detected preoperatively on radiographic studies rather than during autopsy or surgery.1 Treatment options include reduction of the hernia by excision and reimplantation, ureteroscopy or stent placement and observation.3 In addition, recurrence can be prevented by packing the defect with absorbable gauze, closing it with suture or lateral fixation of the ureter.3 In our case a Boari flap was chosen for several reasons, including achievement of a tension-free repair, preservation of a tenuous blood supply and avoidance of recurrence by
placing the flap over the defect, which was covered with suturing adipose tissue. This procedure offers an excellent method for removal of the diseased segment and prevention of further recurrence.
REFERENCES
1. Sto¨ckle, M., Mu¨ller, S. C. and Riedmiller, H.: Ureterosciatic hernia. A rare cause of pyonephrosis. Eur Urol, 16: 463, 1989 2. Arat, A. and Haliloglu, M.: Ureteral-sciatic hernia in a child demonstrated by voiding cystography. J Urol, 160: 157, 1998 3. Rommel, F. M., Boline, G. B. and Huffnagle, H. W.: Ureterosciatic hernia: an anatomical radiographic correlation. J Urol, 150: 1232, 1993
Vol. 164, 776 –777, September 2000 Printed in U.S.A.
URETERAL SCIATIC HERNIA DEMONSTRATED ON RETROGRADE UROGRAPHY AND SURGICALLY REPAIRED WITH BOARI FLAP TECHNIQUE MARK W. NOLLER
AND
DAVID W. NOLLER
From the United States Army Health Clinic, Schweinfurt, Germany, and A Medical Corporation, San Jose, California KEY WORDS: ureter, hernia, surgical flaps, urography
Ureteral sciatic hernias are rare and their etiology varies. Patients can present with vague and nonspecific symptoms, which makes diagnosis difficult. We report a case of a ureteral sciatic hernia revealed on retrograde urography and repaired with a Boari flap technique. CASE REPORT
A 62-year-old woman was admitted to the hospital with the chief complaints of abdominal pain, nausea and decreased appetite 5 days in duration. Initial vital signs and laboratory tests, including urinalysis, were normal. Excretory urography (IVP) showed significant hydronephrosis and hydroureter from the level of the mid pelvis. Abdominal computerized tomography (CT) revealed obstruction of the distal left ureter with herniation into the sciatic foramen (fig. 1). The patient underwent retrograde ureteroscopy, which revealed acute narrowing and 180-degree tortuosity with posterior deviation behind the acetabulum (fig. 2). Attempted passage of a ureteral catheter would not negotiate the acute tortuosity. Left Gibson and muscle splitting incisions were made retroperitoneally to the dilated left ureter. The left ureter was isolated and dissected down to the sciatic foramen, where the ureter invaginated into the foramen. At this point the ureter was markedly fibrotic, tortuous and angulated at 180 degrees. This segment of ureter was excised and taken down to the ureterovesical junction. The proximal ureter was reimplanted into the bladder using a Boari flap technique (fig. 3). No attempt was made to close the hernia because it was covered with omentum. Convalescence was uneventful and the patient was discharged from the hospital 4 days postoperatively.
FIG. 2. Retrograde ureterogram reveals 180-degree tortuosity of left ureter in sciatic foramen.
DISCUSSION
Sciatic herniation of the ureter is uncommon and difficult to diagnose on physical examination. Sciatic hernias seem to occur more frequently in females due to a larger sciatic foramen and wider pelvis. Other predisposing factors include Accepted for publication April 7, 2000.
FIG. 3. Postoperative IVP demonstrates patency of Boari flap.
neuromuscular disorders causing atrophy of the piriform FIG. 1. CT shows passage of calcified left ureter (arrow) into sci- muscle, hip joint diseases and congenital defects in the pelvic fascia.1 More than 11 cases have been reported.2 atic foramen. 776
777
URETERAL SCIATIC HERNIA
Herniation due to a defect in the parietal pelvic fascia is more common in elderly women.3 Diagnoses has been made on IVP, retrograde urography and CT with the use of 3-dimensional reconstruction.3 More of these cases are detected preoperatively on radiographic studies rather than during autopsy or surgery.1 Treatment options include reduction of the hernia by excision and reimplantation, ureteroscopy or stent placement and observation.3 In addition, recurrence can be prevented by packing the defect with absorbable gauze, closing it with suture or lateral fixation of the ureter.3 In our case a Boari flap was chosen for several reasons, including achievement of a tension-free repair, preservation of a tenuous blood supply and avoidance of recurrence by
placing the flap over the defect, which was covered with suturing adipose tissue. This procedure offers an excellent method for removal of the diseased segment and prevention of further recurrence.
REFERENCES
1. Sto¨ckle, M., Mu¨ller, S. C. and Riedmiller, H.: Ureterosciatic hernia. A rare cause of pyonephrosis. Eur Urol, 16: 463, 1989 2. Arat, A. and Haliloglu, M.: Ureteral-sciatic hernia in a child demonstrated by voiding cystography. J Urol, 160: 157, 1998 3. Rommel, F. M., Boline, G. B. and Huffnagle, H. W.: Ureterosciatic hernia: an anatomical radiographic correlation. J Urol, 150: 1232, 1993