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Ureteric inguinal herniation with obstructing bladder tumour

While ureteric orifice obstruction by bladder tumour is common, an inguinal hernia containing ureter is rare. The simultaneous occurrence of both has not previously been reported and made management both challenging and unique. We present the case of a 75-year-old man who presented with a symptomatic right inguinal hernia, which was found on imaging to include the right ureter. Cystoscopy to perform right ureteric stent insertion revealed bladder tumour obstructing the ipsilateral ureteric orifice. A multi-disciplinary approach involving urology, general surgery and interventional radiology was successful in achieving tumour resection, ureterolysis with preservation of ureter and inguinal hernia repair.


Introduction
Inguinal herniation is ubiquitous, with 0.3% of Americans undergoing inguinal herniorrhaphy annually. 1 Ureteral involvement is rare, however, with fewer than 140 reported cases. 2,3 The concurrent presentation of both ureteric inguinal herniation and bladder malignancy is rarer still and has not previously been reported.

Case presentation
A 75-year-old male presented with right inguinoscrotal discomfort and swelling. He denied all other symptoms. On physical inspection, the patient was obese, ambulated easily and had normal vital signs. Abdominal examination revealed a right inguinoscrotal hernia. The hernia measured approximately 10 × 4 × 4cm and was irreducible, non-tender and without cough impulse. Both testes were present and normal to palpation.
His medical history consisted of diabetes mellitus, hypertension, dyslipidaemia, atrial fibrillation, gastro-oesophageal reflux disease and Meniere's disease. He had no prior surgical history. The patient's medications were once-daily oral aspirin 100mg, ezetimibe 10mg, esomeprazole 20mg, cholecalciferol 1000 units, rosuvastatin 20mg and perindopril/indapamide 5/1.25mg. He drank 2 standard drinks of alcohol daily, with prior alcohol abuse, and had never smoked.
Ultrasound demonstrated a right inguinoscrotal hernia, containing a 13 × 3.2 × 1.7cm fluid-filled structure, thought to represent a patent processus vaginalis. No viscera were noted in the sac. Computed tomography abdomen/pelvis with intravenous pyelogram (CT IVP) revealed the right ureter filling the sac, with hydro-uretero-nephrosis ( Fig. 1). The left kidney and ureter were unremarkable. Serum studies showed creatinine 101μmol/L and estimated glomerular filtration rate (eGFR) 62mL/min/1.73m 2 . Complete blood examination was normal.
At urology multi-disciplinary team (MDT) meeting, consensus was reached for urology and general surgical consultants to together perform rigid cystoscopy, right retrograde ureteric stent insertion, ureterolysis and inguinal hernia repair. With informed consent, the procedure commenced with rigid cystoscopy, revealing papillary bladder tumour covering the right ureteric orifice. The intended procedure was abandoned, and transurethral resection of bladder tumour was performed. The right ureteric orifice was then unable to be located, and a urethral catheter was placed. Post-operatively, the patient's renal function deteriorated, with eGFR reaching 18mL/min/1.73m 2 on post-operative day 3. A nephrostomy tube was inserted by interventional radiology, with the patient's eGFR promptly returning to baseline. Bladder histology displayed a non-invasive low-grade papillary urothelial carcinoma. The patient passed his trial of void and was discharged with the right nephrostomy in-situ.
The MDT then formed a second combined approach. After consenting, under general anaesthesia the patient underwent attempted insertion by the interventional radiologist of a right antegrade ureteric stent. A guidewire was placed between the nephrostomy puncture site and bladder. However, due to the tortuous ureter, no ureteric stent had sufficient length to reach the bladder. To aid subsequent ureterolysis, a 4-French ureteric access sheath was placed from nephrostomy puncture site to bladder, traversed by an internal stiff guidewire. The patient was https://doi.org/10.1016/j.eucr.2019.100924 Received 12 May 2019; Accepted 28 May 2019 transferred intubated and sedated to the general operating theatre. Midline lower laparotomy was performed, followed by extra-peritoneal right ureterolysis to the deep inguinal ring. The ureter was found adherent to scrotal skin and irreducible. A separate right inguinal incision was performed, with successful scrotal ureterolysis (Fig. 2). The ureter was then reduced into the pelvis, and the inguinal hernia repaired in the Lichtenstein method.
Rigid cystoscopy was performed, with no further bladder tumour visible. The universal guidewire was exchanged for a 0.038 inch diameter Boston Scientific Sensor™ guidewire, and the ureteric access sheath removed. Right flexible ureteroscopy was unsuccessful due to a distal ureteric stricture. Retrograde placement of a 6-French 30cm ureteric stent was initially also unsuccessful due to the > 30cm ureteric length. However, manual manipulation via the laparotomy incision to shorten the ureter successfully facilitated placement. The patient recovered well and was discharged day nine post-operatively.
Six weeks later, right ureteroscopy was again unsuccessful despite stent dilatation, and the stent was removed. The patient's eGFR remained at baseline. CT IVP two days post-operatively confirmed prompt passage of contrast to bladder, and the patient was discharged.
Two months postoperatively, the patient remains asymptomatic, with normal renal function. Close monitoring is planned to detect the development of either obstructive uropathy or recurrent urothelial carcinoma.

Discussion
Ureteric inguinal herniation is rare. 2,3 Most patients suffer symptoms only from the hernia itself, without flank pain, lower urinary tract symptoms or sequelae of obstructive uropathy. 2 Risk factors are male gender and obesity (factors shared by bladder cancer), with most cases occurring aged 40-60 years 2 and involving the right ureter. Our patient, therefore, comprised a classic presentation of this uncommon disease.
Imaging investigations classically reveal redundant ureter looping into the inguinal region. However, the diagnosis may not be made preoperatively, due to the frequent absence of urological symptoms, and the non-specific sonographic appearance of the ureter in the hernial sac. Inadvertent ureteric injury during herniorrhaphy may ensue, with loss of the renal unit. 2 Treatment goals are symptom resolution and renal preservation. The most common approach involves retrograde ureteric stent placement (although often unsuccessful), followed by open ureterolysis and hernia repair. 2 Pre-stenting is prudent to help distinguish sac from ureter. If retrograde attempts are unsuccessful, the authors recommend attempted antegrade stenting, rather than proceeding without a stent.
Ureterolysis is frequently challenging due to ureteric-scrotal adhesions. Adequate ureterolysis to allow stenting is unlikely to be possible via a purely an abdominal approach. An extra-peritoneal combined inguinal and lower midline laparotomy allows comprehensive ureteric access and rapid patient recovery.   The authors were only able to identify one other case of urothelial carcinoma synchronous with ureteric inguinal herniation. Urothelial carcinoma in this case however was located in the right renal pelvis. 4 Therefore, we believe our patient represents the first report of ureteric inguinal herniation simultaneous with bladder tumour.

Conclusion
Ureteric inguinal herniation is rare. The diagnosis may not be apparent pre-operatively, and the surgeon must be cautious during every herniorrhaphy. Managements goals involve symptom relief and protecting renal function. Operative repair ideally occurs in a multi-disciplinary setting and consists of ureteric stent insertion, laparotomy ± inguinal incision, ureterolysis and hernia repair.

Author contributions
HY and NK conceived the research idea. FH wrote the first manuscript. All authors refined the final manuscript and were involved in the patient's care.

Declarations of interest
None. Written consent was obtained for publication of this case report.