Robotic repair of a rare case of symptomatic “Ureterosciatic Hernia”
A 75-year-old Caucasian woman was referred to us with chronic left-sided flank pain for the past several years. She had a history of an uneventful abdominal hysterectomy performed 6 years back. At presentation, she was afebrile and her general examination was unremarkable, her urine analysis, blood biochemistry including blood urea and serum creatinine were also within normal limits. A plain X-ray KUB did not show any evidence of nephrolithiasis and an ultrasound-KUB revealed left gross hydroureteronephrosis (HDUN). Based on this, we entertained an initial empirical diagnosis of left obstructive uropathy possibly due to a left ureteric stricture/stone. Subsequently, she was planned for a renogram and computed tomography (CT). The radioisotope renogram revealed high-grade obstruction with a compromised left renal function of 17%. The plain CT scan of the abdomen and pelvis (without contrast) done was suggestive of left HDUN with a grossly dilated convoluted ureter till the level of S2-3 vertebra seen on longitudinal cuts [], with protrusion outside the bony pelvis above the piriformis seen on transverse cuts []. Based on the CT, a diagnosis of internal herniation of the ureter was speculated. The retrograde urography study revealed a normal caliber distal left ureter with an abnormal lateral protrusion and looping (curlicue) beyond the bony pelvic margin at the level of the sciatic foramina []; this confirmed the diagnosis of an USH. The obstructed left renal unit was drained with a percutaneous nephrostomy (PCN) as prior multiple attempts at retrograde placement of a left guide-wire across the looped and partially obstructed left ureter had been unsuccessful. Subsequently through this PCN, an antegrade guide wire was passed which depicted a fixed kinking of the ureter [] and ureteric stenting was successfully performed. She initially elected to remain on observation, though complaining of severe discomfort with the stent. Her pre-stent renal function was 17% in the left kidney. A second renal scan was done after six weeks of stenting and the left renal function was now up to 38% (post-endourological stenting with the stent in situ). Later, at six weeks, the stent became so intolerable that she elected to have it removed and decided for a definitive surgery. After discussing the various surgical options with the patient, she elected to undergo a robot-assisted laparoscopic repair of her left USH.\nThe robot-assisted laparoscopic procedure was initiated under general anesthesia with the patient in steep trendelenburg position, pneumoperitoneum, and four ports. A robot-assisted meticulous laparoscopic reduction of the left USH (at the point where the distal ureter was identified entering the sciatic foramen) and ureterolysis (releasing from surrounding adhesions) were carried out successfully. The released ureter from hernial sac appeared well vascularized; thus, we decided not to excise the ureter and employ ureteroneocystostomy. A ureterotomy was made for retrograde insertion of a 26 cm/6Fr JJ stent, which was done successfully, and the ureterotomy was closed using 5-0 polyglactin absorbable suture. The hernial defect was repaired in two layers with a 3-0 nonabsorbable polypropylene suture in a running manner. The patient made an uneventful rapid recovery and the operating time, blood loss, and hospital stay were 90minutes, <50 ml, and 18 hours, respectively. At the 10th week of follow-up, her JJ-stent was removed in our outpatient clinic. Later at 3 months follow-up, her renogram left renal function improved to 43%; currently, the patient is doing well [].