The dilated ureter in the hernial sac of the patient suspected us of ureteral herniation as a possible cause of obstruction evidenced by the severe hydronephrosis, more details were obtained by the nephrostogarphy. Antegrade uretroscopy was done to alleviate the ureterovesical junction stenosis and double-J catheter insertion.
Ureteral obstruction and urinary fistulae account for 95% of urologic complications in renal transplantation (3
). Herniation of the transplant ureter is a rare complication and can cause or exacerbate ureteral obstruction (2
). Ureteroingunal hernias of native kidneys are classified into two major groups, depending on the presence or absence of a concomitant peritoneal hernia sac. The para (intra) peritoneal type is accompanied by a herniated peritoneal sac adjacent to the ureter. In the rare extraperitoneal type, only the ureter hernaites through the inguinal canal, frequently surrounded by abundant retroperitoneal tissue (2
Ultrasound is usually the first examination to diagnose obstructive uropathy in patients with renal implantation. If physical examination demonstrates an inguinal hernia on the same side as an obstructed transplanted kidney, sonographic evaluation should be performed to determine whether the ureter is obstructed at this level (2). In most cases of described ureteroinguinal hernia the diagnosis was made by IVP (5
). It reveals superimposition of the afferent and efferent limbs of the ureter as it traverses the hernia sac, producing the pathognomonic “loop -the-loop” or “curlicue” ureter. CT urography, an important alternative to IVP, can demonstrate the uretroinguinal hernia and accompanying pathologic changes rapidly and with better resolution (5
Factors that may contribute to inguinal hernaition of the transplant kidney are the existence of a redundant ureter (as in our patient), placement of donor ureter over the spermatic cord and obesity (1
). Although surgical repair is recommended in all cases of ureteroinguinal hernia, conservative treatment can be a satisfactory alternative in patients with high risk of surgery (8
). As is the case with our patient, renal function returned to normal after conservative management by ureteroscopic dilation and catheter insertion, yet no long-term follow-up was possible as the patient died four months later.