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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2016  |  Volume : 27  |  Issue : 3  |  Page : 614-616
Report of a kidney recipient with inguinal herniation of the transplant ureter


1 Department of Nephrology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran

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Date of Web Publication13-May-2016
 

How to cite this article:
Soleymanian T, Kalantarian T, Radmard A. Report of a kidney recipient with inguinal herniation of the transplant ureter . Saudi J Kidney Dis Transpl 2016;27:614-6

How to cite this URL:
Soleymanian T, Kalantarian T, Radmard A. Report of a kidney recipient with inguinal herniation of the transplant ureter . Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2022 Jan 16];27:614-6. Available from: https://www.sjkdt.org/text.asp?2016/27/3/614/182442
To the Editor

Ureteral obstruction is one of the common urologic complications after renal transplan- tation. Inguinal herniation of ureter of the transplanted kidney is a rare cause of this obstruction. We report a case of late kidney transplant failure owing to ureteral herniation with subsequent ischemia and stricture of distal ureter.

A 48-year-old man, who was on hemo- dialysis for two years for end stage kidney disease secondary to autosomal dominant poly- cystic kidney disease (ADPKD) and under- went renal transplantation from a deceased donor four months earlier, presented with rising serum creatinine. Although his trans- plantation was complicated by delayed graft function, after seven days renal function recovered to almost normal level. One month after discharge, his serum creatinine level was

1.3 mg/dL, and daily immunosuppressive drugs consisted of tacrolimus 4 mg/day, mycopheno- late mofetil 2 g/day, and tapering doses of prednisolone. After that, the course of trans- plantation was uneventful with stable serum creatinine and normal allograft ultrasound. In the 5thmonth after transplantation, he pre- sented with serum creatinine 1.7 mg/dL. His serum tacrolimus level was 9 ng/dL, and other laboratory data were within normal range. He had no complaints and examination was un- remarkable except for two large native cystic kidneys. Tacrolimus dose was decreased to 3 mg daily along with a request of ultrasound for the transplant kidney and recheck of serum creatinine level. After a week, he returned with a serum creatinine level of 3.8 mg/dL and mild to moderate hydronephrosis of the allograft. Serum tacrolimus level was 5 ng/dL. He was admitted for evaluation of rising serum crea- tinine and hydronephrosis of the graft kidney. During admission, serum creatinine increased to 4.5 mg/dL without significant change in urine output. X-ray of kidneys, ureters, and bladder disclosed no stone. Diuretic renal diethylene-triamine-pentaacetic acid (DTPA) scan revealed mild delay in perfusion and initial uptake of the transplanted kidney along with delayed excretion and appearance of the bladder even after Lasix injection [Figure 1]a. Magnetic resonance urography (MRU) of the allograft showed moderate hydrouretero- nephrosis owing to herniation of the transplant ureter into the inguinal region and two very large native kidneys that had pushed the allo- graft down [Figure 1]b and c. Nevertheless, radiologist recommended allograft biopsy because he believed that the obstruction might not explain in full the rising serum creatinine. Kidney biopsy sample was taken which re- vealed normal result except for mild calci- neurin inhibitor toxicity; therefore, the reci- pient was taken up for elective surgery.
Figure 1:

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On exploration, distal of transplanted ureter reportedly was severely fibrotic. Release of ureter, ureteroplasty, and ureterovesical re- anastomosis along with insertion of double J catheter was performed. Two days after the operation, serum creatinine got reduced to 2.5 mg/dL, and he was discharged one week later with a serum creatinine of 2 mg/dL. Three weeks later, his serum creatinine level was 1.6 mg/dL. After extraction of double J stent, follow-up MRU was performed which revealed no remarkable hydronephrosis or hydroureter after administration of intravenous furosemide, and luminal dia-meter of the distal ureter was within normal limits in without any evidence of stricture [Figure 1]d. After 20 months of follow-up, his serum creatinine was still stable (1.2 mg/dL).

Urinary tract obstruction and leakage are two major causes of urinary tract complication in kidney transplant patients (2-10% of cases). Late obstruction is usually secondary to ure- teral scars due to ischemia or rejection.[1],[2]One of the rare causes of ureteral obstruction is ureteral herniation into the inguinal canal.[3],[4],[5],[6]Paraperitoneal and extraperitoneal ureteral her- niation are two types of inguinal herniation of the transplant ureter. In the extraperitoneal herniation, like in our case, only herniation of the ureter through the inguinal canal was observed.[7]Obesity, placement of donor ureter over the spermatic cord, and redundant ureter are the major contributing factors for inguinal herniation of ureter.[8]In our ADPKD recipient, increased intra-abdominal pressure due to large kidneys had probably major role in pushing transplant kidney down and as a result caused ureteral herniation. Stretching of the ureterovesical anastomosis by the herniated ureter would lead to its ischemia, fibrosis, and stricture.

 
   References Top

1.
Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1,000 conse- cutive renal transplant recipients. J Urol 1995; 153:18-21.  Back to cited text no. 1
    
2.
Humar A, Matas AJ. Surgical complications after kidney transplantation. Semin Dial 2005;18:505-10.  Back to cited text no. 2
    
3.
Ingber MS, Girdler BJ, Moy JF, Frikker MJ, Hollander JB. Inguinal herniation of a transplant ureter: Rare cause of obstructive uropathy. Urology 2007;70:1224.e1-3.  Back to cited text no. 3
    
4.
Furtado CD, Sirlin C, Precht A, Casola G. Unusual cause of ureteral obstruction in trans- plant kidney. Abdom Imaging 2006;31:379-82.  Back to cited text no. 4
    
5.
Odisho AY, Freise CE, Tomlanovich SJ, Vagefi PA. Inguinal herniation of a transplant ureter. Kidney Int 2010;78:115.  Back to cited text no. 5
    
6.
Mukha RP, Devasia A, Thomas EM. Ureteral herniation with intermittent obstructive uropathy in a renal allograft recipient. Urol J 2011;8:98.  Back to cited text no. 6
    
7.
Otani LH, Jayanthi SK, Chiarantano RS, Amaral AM, Menezes MR, Cerri GG. Sono- graphic diagnosis of a ureteral inguinal hernia in a renal transplant. J Ultrasound Med 2008; 27:1759-65.  Back to cited text no. 7
    
8.
Pourafkari M, Ghofrani M, Riahi M. Inguinal herniation of a transplant kidney ureter: A case report. Iran J Radiol 2012;10:48-50.  Back to cited text no. 8
    

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Correspondence Address:
Dr. Tayebeh Soleymanian
Department of Nephrology, Shariati Hospital, Tehran University of Medical Sciences, Tehran
Iran
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DOI: 10.4103/1319-2442.182442

PMID: 27215262

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