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Obstructive Uropathy Secondary to an Indirect Extraperitoneal Ureteral Inguinal Hernia

The incarceration of retroperitoneal structures within an inguinal hernia is a rare occurrence. As described by case reports and case series, obstructive uropathy secondary to ureteral inguinal hernia (UIH) is even less common.13 Most (80%) UIHs are paraperitoneal, indicating that an anteromedial hernia sac is present with the ureter that is drawn into the canal along the posterior aspect of the peritoneum.13 However, some (20%) cases of UIH are extraperitoneal, indicating a hernia sac is not present and the ureter is accompanied by retroperitoneal fat.13 In this case, we discuss a patient who was found to have obstructive uropathy secondary to an indirect extraperitoneal UIH. A 60-year-old male with history of hypertension, chronic kidney disease, obesity, obstructive sleep apnea, and gout presented to the emergency department with increased scrotal edema and pain. On physical examination, the patient was found to be obese and with bilateral scrotal enlargement, right greater than left. Hydroceles were suspected given that there was transillumination of the scrotum. Scrotal ultrasound revealed bilateral hydroceles and normal-appearing testicles with appropriate blood flow. He was found to have acute on chronic kidney injury and was hospitalized. During his hospital course, the patient was noted to have benign prostatic hypertrophy with inguinal hernias and incarcerated ureters bilaterally on abdominal CT scan (Fig. 1). Hydronephrosis was noted most prominently on the right and mildly on the left. Further evaluation with radioisotope renography revealed atrophy of the left kidney, with normal residual function of the right kidney. A foley catheter was placed before renography. Due to persistent hydronephrosis, a right-sided percutaneous nephrostomy tube was placed by interventional radiology. The patient’s hospital course was complicated by a gastrointestinal bleed, whose source was never identified despite endoscopy and that did resolve with nonoperative management. The patient was eventually discharged home with right-sided nephrostomy tube and foley catheter in place. During the patient’s initial hospitalization, urological and general surgical consultations were obtained by the primary admitting team. Outpatient combination of inguinal hernia repair with possible ureteral reimplantation was planned. After multidisciplinary discussion, the decision was made in combination with the patient to move forward with right-sided inguinal hernia repair with possible ureteral reimplantation and observation of the left inguinal hernia. Although the left inguinal hernia contents seemed to include incarcerated ureter and retroperitoneal fat, renal atrophy was already present and the patient experienced minimal symptoms of pain or discomfort on the left side. Right Lichtenstein inguinal hernia repair was performed. Intraoperatively, a dilated 2-cm incarcerated ureter and retroperitoneal fat were noted (Fig. 2). This was reduced without difficulty and hernia repair followed. A true hernia sac was never identified, and the defect was indirect. Urology performed cystoscopy, cystogram, and complicated foley placement over a guide wire following the hernia repair. They reserved ureteral implantation for a later date. The patient was