Case No. 2: When Urine Trouble – Recall the Basic Principles of General Surgery

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AUTHOR: I. Georgescu, MD MSc

STAFF SPONSORS: ZM. Mir, MD MSc and S. Hiebert, MD MSc FRCSC

UNIVERISTY AFFILIATION: Dalhousie University

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CASE PRESENTATION:

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A 56-year-old male, with a remote history of a right kidney transplant, presents with significant graft dysfunction in the context of a complicated right inguinal hernia. His past medical history includes diabetes requiring insulin, hypertension, dyslipidemia, gastroesophageal reflux disease, gout, and non-alcoholic fatty liver disease. Patient remains on the usual immunosuppressive medications and has no history of prior surgeries outside of the previous transplant. BMI is of 23.

Patient was initially assessed in clinic for outpatient hernia repair where his creatinine was found to be elevated. He was subsequently transferred to the QEII Health Sciences Centre for evaluation by the transplant team.

Physical examination reveals a hemodynamically stable patient with a soft, non-tender abdomen, and a non-tender, non-reducible right inguinal hernia. Patient is largely asymptomatic with no fevers or urinary symptoms reported. Laboratory workup is significant for a creatinine of 643 but no leukocytosis. Computed tomography of the abdomen and pelvis demonstrates hydronephrosis of the transplanted kidney, with a dilatated ureter seen extending into a right inguinal hernia. Query obstructive uropathy.

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SURGICAL INTERVENTION:

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Patient undergoes emergent surgery for graft salvage and obstruction relief. Hernia is accessed via an open incision at the level of the external ring. Careful dissection reveals an indirect inguinal hernia. The sac is noted as soft and fat-containing, with no obvious ureter palpable. The defect is repaired using a patch repair as per the Lichtenstein technique. Overall, the procedure is uncomplicated.

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POST-OPERATIVE COURSE & OUTCOMES:

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Uneventful postoperative course. Hospital admission totalling five days. Urine output and creatinine are improved at time of discharge. Graft function and creatinine remain favourable at two-week follow-up. Plan for repeat CT imaging at future follow-up to visualize the unobstructed ureter.

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POINTS OF DISCUSSION:

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1. Open vs. laparoscopic repair in the context of ureteroinguinal hernia.

-The laparoscopic approach requires a more specialized skill set and has not been described in the literature as often as the open approach in the context of ureteroinguinal hernia.

2. Role for cystoscopy and preoperative stent placement and/or indocyanine green for ureteral protection when suspicion for a ureteroinguinal hernia is high.

-Transplanted ureters may present with significant angulation that may not be amenable to stenting. Additionally, access to cystoscopy and indocyanine green may be limited depending on the operating centre.

3. Can a ureteroinguinal hernia be safely managed in a community setting, or does it require transfer to a more experienced centre?

-Our repair was performed with oversight from a multidisciplinary team of transplant general surgeons, transplant urologists, and transplant nephrologist to increase the likelihood of a positive outcome. The same repair should be able to be performed by a community surgeon.

4. The use of Lichtenstein mesh repair vs. primary repair techniques?

-Tension-free mesh repair minimizes the risk of recurrence in a high-risk patient with no evidence of contamination or bowel compromise.

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CASE SELECTION: 

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Qualities that make this case report worthy of selection include its asymptomatic presentation, its unique patient population, and its rarity. Additionally, despite being a rare phenomenon, knowledge of ureteroinguinal hernia diagnosis and management involves basic general surgery principles that should belong in the armamentarium of any practicing general surgeon, especially new graduates and those practicing in an acute care setting.