In a kidney transplant recipient, bladder and graft ureter displacement into a groin hernia is a highly unusual cause of obstructive uropathy that may lead to graft dysfunction or graft loss. We report the case of a White man, 56 years old, who had previously, at the age of 19 years, undergone a kidney transplant from a deceased donor, to mitigate chronic glomerulonephritis. The patient presented to us with a reducible left inguinal hernia with worsening kidney function, and we used the Lichtenstein hernioplasty technique to surgically repair the hernia, which was followed by an uneventful postoperative course. Existing literature has identified few cases of kidney graft dysfunction due to inguinal hernias. Groin hernia repair of this type in this specific circumstance remains a subject of debate. However, in our opinion, with attention to appropriate reductions of immunosuppressive therapy, the Lichtenstein technique is safe for transplant recipients and the use of mesh greatly reduces the risk of hernia recurrence.
Key words : Inguinal hernia, Lichtenstein hernioplasty, Worsening kidney function
In kidney transplant recipients, bladder and graft ureter displacement into a groin hernia is a highly unusual cause of obstructive uropathy that may lead to graft dysfunction or graft loss. Existing literature has identified few cases of kidney graft dysfunction due to inguinal hernias.1,2 Groin hernia repair of this type in this specific circumstance remains a subject of debate.
Written informed consent was obtained from the patient for publication of his clinical details and clinical images.
We report the case of a White man, 56 years old, who had previously, at the age of 19 years, undergone a kidney transplant from a deceased donor, to mitigate chronic glomerulonephritis. The kidney graft was placed in the left iliac fossa in the extraperitoneal space. The renal artery and the renal vein were anastomosed to the external iliac vessels of the recipient, and the ureter was connected to the bladder throughout a direct anastomosis according to the Lich-Gregoir technique. Thirty-five years after the transplant, immunosuppression was maintained with azathioprine (50 mg daily) and prednisolone (15 mg on alternate days).
After the transplant, the patient had stable renal function with a slow increase of serum creatinine up to 1.8 mg/dL and proteinuria. The patient was affected by left inguinal hernia for the past 10 years but never underwent surgical examination. During the usual nephrological follow-up, routine blood tests showed a sudden increase in serum creatinine to 2.3 mg/dL without any sign of infection, rejection, or fluid restriction and all without any modification of therapy. The patient complained occasionally that he had to reduce the groin hernia with manual pressure in order to urinate properly. Transabdominal sonographic examination showed hydronephrosis of the graft with slight ureteral dilation and hyperechoic foci in the upper calyceal group. The ultrasonography findings suggested nephrolithiasis, which was not confirmed by unenhanced computed tomography. Computed tomography scan identified that the lateral part of the bladder and the distal part of the graft ureter had slipped into the groin hernia, which caused ureteral and renal pelvis dilation and most likely impaired kidney function. The ureteral dilatation was 11 mm, whereas the anterior/posterior diameter of the renal pelvis was about 47 mm (Figure 1). At this point of the clinical work, the patient was referred to our surgical unit.
On physical examination, the groin hernia was reducible. The patient underwent surgical hernia repair according to the Lichtenstein hernioplasty technique. The lateral part of the bladder, including the ureteroneocystostomy and the distal part of the graft ureter, was herniated into the inguinal canal through a direct hernia. A polypropylene mash was used to bridge the gap between the conjoined tendon and inguinal ligament. Antibiotic prophylaxis of 2 g cefazolin was administrated intravenously to the patient just before surgery. An uneventful postoperative course followed.
One month after surgery, serum creatinine level decreased from 2.3 to 1.8 mg/dL, which was the patient’s base line. An unenhanced abdominal computed tomography scan showed a left ureter without any sign of dilatation and that the left renal pelvis anterior/posterior diameter had dropped from 47 to 23 mm.
A bladder or graft ureter displacement into a groin hernia sac in a kidney transplant recipient is a rare event with few cases reported in the literature. This case presented the following 2 problems: the timing for surgery and the type of hernia repair in a transplant recipient on immunosuppressant therapy. Although unusual, this sort of problem may cause an obstructive uropathy that results in an acute or chronic decrease of graft function. In the case reported, the bladder and the graft ureter of the patient were not incarcerated or strangulated in the groin hernia. The hydronephrosis was mild, and the serum creatinine value increased slowly. For this reason, we did not proceed to placement of a percutaneous nephrostomy tube nor a ureteral stent before surgery. In case of acute hydronephrosis with sudden decrease of kidney function, the hernia repair should be performed after appropriate drainage of the renal pelvis when the serum creatinine reaches its baseline value. We surgically repaired the groin hernia with a mesh according to the Lichtenstein technique. We also considered that the patient had been treated with steroids for more than 35 years, which meant that he had an impaired healing. As a consequence, a primary non-mesh tissue repair of the groin has a high risk of hernia recurrence.
On the other hand, the patient’s state of immunosuppression could facilitate a mesh infection.3-6 For this reason, some practitioners prefer to perform a non-mesh groin hernia repair in transplant recipients (for example, the Shouldice 4-layer inguinal hernia repair technique).2 A recent review of the literature reported 32 groin hernia repairs to mitigate the ureteral obstruction caused by herniation of the transplanted ureter. In 13 cases (40%), a mesh had been used.1 Open mesh versus non-mesh groin hernia repair is associated with reduced risk of recurrence of 50% to 75%.7,8 Moreover, the recurrence rate for primary hernia repair during the pre-mesh era has been reported as 10% to 30%.9 Some practitioners have not found any significant difference in prosthetic incisional hernia repair between kidney transplant recipients and nontransplant patients with regard to wound-related complications, recurrence rates, and mesh incorporation.10
In this particular case, the immunosuppression level 35 years after transplant was very low; therefore, based on the literature and our 20 years of experience, the risk of recurrence in a primary hernia repair was considered higher than the risk of infection through use of a mesh.
Inguinal herniation of part of the bladder or graft ureter, although rare, may be a factor in kidney dysfunction caused by an obstructive uropathy. If detected early, surgical correction may result in graft function recovery. Timely intervention instead of observation is recommended to repair groin ipsilateral hernias when formed after kidney transplant. A noncontrast computed tomography scan may provide better anatomic results and feedback on the kidney transplant and ureter than would an ultrasonographic examination. In the perioperative period, immunosuppressive therapy should be reduced to the lowest level possible, and some categories of immunosuppressant therapy, such as inhibitors of the mammalian target of rapamycin, should be avoided. In our opinion, the Lichtenstein technique is safe for transplant recipients and the use of mesh greatly reduces the risk of hernia recurrence.
Volume : 19
Issue : 1
Pages : 80 - 82
DOI : 10.6002/ect.2020.0487
From the 1General Surgery and Abdominal Organ Transplantation Unit, ASST
Niguarda Hospital, Milan, Italy; the 2Department of Medicine and Surgery,
Bicocca University of Milan, Milan, Italy; the 3Department of Diagnostic and
Interventional Radiology, ASST Niguarda Hospital, Milan, Italy; 4Sapienza
University of Rome, Rome, Italy; and the 5Department of Oncology and
Hemato-Oncology University of Milan, Milan, Italy
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential interest.
Corresponding author: Alessandro Giacomoni, General Surgery and Abdominal Organ Transplantation Unit, ASST Niguarda Hospital, Milan, Italy
Figure 1. Unenhanced Computed Tomography Scan Showing the Lateral Part of the Bladder and the Distal Part of the Graft Ureter Herniated Into Left Inguinal Hernia