ureteric injury from herniorrhaphy is unusual . we present a case of ureteric injury complicating an inguinal herniorrhaphy for a huge right inguino - scrotal hernia .
case reports are important as they describe rare clinical conditions , highlight uncommon challenges or therapeutic adaptations .
they can , however , draw attention to uncommon sequel of standard treatment to serve as caution in future practice .
ureteric injury following herniorrhaphy is rare .this is probably the first reported case from nigeria .
we present a 66-year - old male farmer with right inguino - scrotal swelling noticed 10 years earlier which became irreducible 2 years prior to presentation .
he had dysuria , urgency , urge incontinence , and feeling of incomplete emptying of the urinary bladder .
he had a chronic dry cough and smoked two packets of cigarette per day in last 15 years .
his respiratory rate , pulse rate and blood pressure were 22 cycle per minute , 100 beats per minute and 200/120 mmhg respectively .
a provisional diagnosis of lower urinary tract infection ( uti ) , incarcerated right inguino - scrotal hernia with bladder outlet obstruction due to prostatic enlargement was made .
the complete blood count , fasting blood sugar , serum electrolytes , urea , and creatinine , prostate - specific antigen , urine microscopy , culture and sensitivity , chest x - ray , and elecrocardiography done were all normal .
ultrasonography revealed a thickened urinary bladder wall , bilateral pelvi - calyceal dilatation of kidneys but the ureters could not be visualized .
scrotal ultrasound reported a large cystic mass on the right extending into the groin and surrounded by loops of bowel .
intraoperative findings were : a right pantaloon hernia sac ( the indirect sac containing an inflamed appendix about 16 cm in length , while the direct sac component contained grossly normal cecum and the urinary bladder ) .
the right ureter was inadvertently transected during dissection which necessitated laparatomy and conversion from spinal anesthesia to general anesthesia .
the patient had bassini - type right inguinal herniorrhaphy and reimplantation of the transected right ureter into the urinary bladder over a transvesical ureteric stent ( figure 1 and 2 ) an urologist at the same session .
surgery lasted about 3 h. he developed features of systemic inflammatory response syndrome ( sirs ) which progressed to multiple organ failure culminating in death by the fourth day postsurgery .
. probable cause of death was septicemia with multiple organ failure . showing the transected ureter held with a clamp . showing the insertion of size 5 feeding tube as a stent postureter - neocystostomy .
groin hernia surgery demands sound knowledge of the anatomy of the region as it does the principles of good perioperative care .
complications may arise from groin hernia repair ; these commonly include : hemorrhage , surgical site infection , numbness of groin , chronic pain , and abnormal scar .
injuries to gut and bladder can occur during repair of complicated hernias ( incarcerated , obstructed or ischemic / gangrenous ) and in hernia - en - glissade . the latter type was noted in our patient .
generally ureteric injuries are either caused by external violence , usually penetrating missiles , or more commonly from surgical misadventure .
. the most common procedures are hysterectomy , salpingo - oophorectomy , vesico - urethral suspension , ureteroscopy , endo - pyelotomy , and uretero - lithotomy and surgical procedures on the great vessels and colon as well as retroperitoneal tumor excision . lately , laparoscopic procedures have become a common cause of ureteric injuries .
it is likely to occur if the ureter forms part of the sac or is contiguous with the spermatic cord as was seen in this patient .
ureteric herniation can either have a peritoneal covering ( para - peritoneal herniation , 80% ) , or lacks peritoneal covering ( extraperitoneal , 20% ) .
para - peritoneal ureteric hernia is common on the right , in males between fourth and sixth decades of life , and occurring in association with a sliding indirect hernia .
the patient also had uti , symptomatic prostatic enlargement , and hypertension ; all of which could promote adverse surgical outcome .
ureters within the hernia sac or contiguous to it can be identified as a thickened cord which exhibits peristalsis especially when stimulated , and contain fluid ( urine ) on test aspiration .
the lower urinary symptoms ( luts ) noted in the patient could have been from the prostatic enlargement or from the involvement of the bladder in the hernia process or from the uti .
the presence of prostatic enlargement with dilatation of proximal urinary tract as seen in our patient was previously reported by kate et al . .
preoperative diagnosis of groin hernia containing the ureter or bladder can be made with a micturating cystogram   or an intravenous urogram .
early detection at time of injury and primary repair is said to confer better prognosis .
intraoperative localization of point of ureteric injury can be achieved using intravenous 5 ml of indigo carmine intravenously and observing its extravasations into the periureteric tissues .
the diagnosis of a ureteric injury generally is not made until many days after the injury has occurred .
most common signs and symptoms seen in these patients are flank pain , fever , anuria ( if bilateral ) , uretero - vaginal fistula , and uretero - cutaneous fistula . in these conditions , an excretory urogram or computerized tomography ( ct )
if the patient is scheduled for exploration or the presence of an injury is in doubt , then a retrograde ureterogram is strongly advised .
uretero - neocystostomy can be used to repair distal ureteric injuries that occur so close to the bladder thus precluding need for a  psoas hitch  or boari procedure .
mortality is said to be worse in the elderly , following emergency procedure and in the face of comorbid diseases .
the mortality recorded may be due to his high preoperative cardio - pulmonary risk status ( long - term smoking with chronic cough , and severe hypertension ) ; long duration of surgery in an elderly patient who had spillage of potentially infected urine in to the surgical wound .
the resultant septicemia from the latter coupled with the metabolic response to surgery in an already challenged cardio - pulmonary system could be enough to tip him into sirs and finally death from multiple organ failure .
we can not categorically state the primary cause of death ; an autopsy would have helped elucidate this .
complete inguinal hernia may contain the lower urinary tract especially if the patient presents with luts .
preoperative radiological evaluation is advised in such cases to avoid injury to the ureter and/or bladder .
 key clinical messageherniorrhaphy is a common surgery worldwide . 
 common complications include hemorrhage , infection , chronic pain , and recurrence . 
 ureteric injury from herniorrhaphy is unusual . 
 we present a case of ureteric injury complicating an inguinal herniorrhaphy for a huge right inguino - scrotal hernia . 
 patient had primary uretero - neocystostomy but died from septicemia in the postoperative period . 