Internal retroureteral hernia after radical cystectomy: A case report

INTRODUCTION

Internal hernias in the pelvic cavity are rare, an internal hernia caused by the ureter is an extremely rare event: only 5 cases have been reported worldwide. These five cases coincide with previous urinary diversion surgical procedures.

CLINICAL CASE

82-year-old male, surgical history of interest: prostatic acinar adenocarcinoma pT2B operated on in May 2019 and sigmoid colon adenocarcinoma pT3N0M0 operated on in December 2019. During follow-up for his prostate pathology, he was diagnosed with invasive bladder urothelial carcinoma and scheduled surgery was decided to perform open radical cystectomy with Bricker-type urinary diversion.

During the surgical procedure, an iatrogenic perforation of the anterior aspect of the rectum measuring 7cm in length was detected and a Hartmann's procedure was performed. The postoperative period was torpid with nausea and vomiting which required the placement of an NGT. On the 6th postoperative day, due to the absence of improvement and worsening blood tests with an increase in AFR (16900 leukocytes/mm3, CRP 144mg/dl), NGT (1500cc in 8 hours) and non-functioning colostomy, an abdominal X-ray was performed, showing: Dilatation of intestinal loops in the pattern of piles of coins, for which reason a CT scan of the abdomen was performed, showing dilatation of the intestinal loops compatible with paralytic ileus, which was treated conservatively, with a functioning colostomy on the 9th postoperative day.

On the 10th postoperative day, the patient began with abundant drainage of peritoneal fluid through the surgical wound and, on suspicion of evisceration, urgent surgery was decided. Intraoperatively, herniation of the small bowel loops into the pelvis was observed through an orifice formed by the left ureter, the ileal conduit and the retroperitoneum; no intestinal vascular compromise was observed. Herniated contents were reduced and the left ureter was fixed to the retroperitoneum.

CONCLUSION

Small bowel obstruction due to internal hernia caused by urinary diversion is an extremely rare occurrence but must be considered in the differential diagnosis of post-surgical complications.

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