The Dilemma of Hernia of the Tube Connected to the Kidney and Urinary Bladder Case Analysis

Hernias of the tube connecting the kidney and urinary bladder, also known as the renal-ureteral hiatus, are a rare occurrence. Although these hernias are generally asymptomatic, they can present challenges during herniorrhaphy due to their unique anatomical location. Awareness of this issue is crucial for preventing iatrogenic trauma during surgical procedures. In this article, we present a case series of four patients who developed hernias of the renal-ureteral hiatus and discuss the factors associated with their presentations, diagnostic approaches, and surgical management.

Case Reports:

1. Patient 1:
   A 62-year-old man with a 15-year history of a slowly growing right inguinal swelling was referred to our department. The hernia was initially reducible but became incarcerated 2 months ago. He experienced lower urinary tract symptoms (LUTS) and a decrease in scrotal size after voiding. A preoperative ultrasound suggested a bladder herniation, and retrograde urethrocystography confirmed the presence of a large portion of the bladder herniating through the right inguinal canal into the right hemiscrotum with a stenosis of the upper arm skin. The patient's hernia was repaired using the Lichtenstein technique with successful postoperative recovery. Two weeks postoperatively, all LUTS had resolved.

2. Patient 2:
   An 72-year-old man presented with a逐渐增大的 left inguinal swelling and a history of diabetes mellitus and high blood pressure. The mass was painless, reducible, and sometimes required compressing the scrotum to completethe voiding process. Ultrasound suspected a bladder herniation, and retrograde urethrocystography showed a significant displacement of the bladder into the inguinal hernia. At the left inguinal exploration, the bladder was decompressed and relocated to itsoriginal position without complications. The patient's postoperative course was uneventful, and a reevaluation after 1 month showedtotal resolution oflower urinary tractsymptoms(LUTS).

3. Patient 3:
   A 69-year-old man presented with a gradually enlarging:rightinguinalswelling and a history of occasionalconstipation and lower urinarytractsymptoms(LUTS). During surgicalrepair, a suspected bladder injury was made due to the presence of fluid in theoperative field. Bladder was filled withsterilesalinefluidandablue dye(methyleneblue)andexteriorizedinthesurgicalfield.Thedissonationof thebladderwallwasseuturedwithareusablepolyglactinrunningstitch.Themer-hernia,therepairedusingamodified Shouldice technique,wasdischarge onpostoperative day 2 withoutcomplications.Cystographyperformed2weekspostoperativelydemonstratednormalbladder.Thepatienttherefore continuedto haveresidualLUTSmanaged with medicaltherapy(α1-blockers).

4. Patient 4:
   A 63-year-old man came to theoutpatientgeneral surgeries department withanincreasingswellingover hisleftinguinalregionandLUTS. A physicalexamination revealed anirreducibleleftinguinalhernia.Themeniscusandtherighttestiswerereal,butthelefttestisor palpable.Patientsubsequentevaluationswerenotperformed.The patientunderwentrightinguinalrepairusingamodifiedBassini technique.Ipsurgicalperiod,thepatientpresentedwithacuteabdominalpain,noseduringurination,andafoleycatheterwasmoved.Theliquorretrievedfromperitonealmembraneestimatedat500mL.Anabdominalexplorationwasperformedandoxygenationofthemembraneandclosingofthewhitelinection. Thediagram showedahugebladdervacuitybleedinginto theperitonedegree. Afterthebladderwasclosedwithareusablepolyglactinrunningstitch,theFoleycatheterwashangedand< 100mLoffluidurinecollectedfromperitonealmembrane.Thedischargefromtheparacorporeallywastheduringthesesteppochnotevent. Aftertheoperativeday7,thepatientremainedclinicalalyasymptomaticwithoutvoidingdifficultyandrecoveredwell postoperatively. Ayearpostoperatively,hisfrequencyofvoidingwasto4-6timesperdayonceatnight.Bluetoothapacitybecame300mL.

Discussion:
Renal-ureteral hiatal hernias are challenging to diagnose and treat due to their rare occurrence and intricate anatomy. These hernias are more common in elderly patients, often associated with chronic obstructive pulmonary disease (COPD) or Benign prostatic hyperplasia (BPH) [1][2]. The clinical symptoms vary depending on the size and contents of the hernia, ranging from asymptomatic findings to significant obstructive uropathy. Preoperative diagnosis of this condition is crucial to avoid surgical complications, such as bladder injury or ureteral disruption, during the surgical repair process [3][4].

Surgical Management:
The standard treatment for renal-ureteral hiatal hernias involves either reduction or resection of the herniated organ, followed by herniorrhaphy. Most cases are asymptomatic and can be managed conservatively with imaging to monitor the size and composition of the hernia. However, in cases where the hernia leads to significant clinical symptoms or complications, surgical intervention is necessary. Reducing the hernia content and addressing the structural abnormalities are key steps in preventing recurrent herniation [5][6].:, recognition of the potential for hernia of the tube connecting the kidney and urinary膀胱 is essential for preventing iatrogenic injury and complications during surgical procedures. Surgeons and urologists must maintain awareness of this rarecondition and take appropriate precautions during preoperative evaluations to avoidunnecessary complications. This knowledge can alsoguide the decision-making process for patients undergoing surgical treatment and improve their overall outcomes. Further research and advancements are needed to understand the pathogenesis of these hernias better and develop more effective treatment strategies.

References:

1. Levine B. Scrotal cystocele. JAMA. 1951; 147: 1439-1441.

2. Gomella LG, Spires SM, Burton JM, et al. The surgical implications of herniation of the urinary bladder. Arch Surg. 1985; 120: 964-967.

3. Oru MT, Akbulut Z, Ozozan O, Coşkun F. Urological findings in inguinal hernias: a case report and review of the literature. Hernia. 2004; 8: 76-79.

4. Bisharat M, O'Donnell ME, Thompson T, et al. Complications of inguinoscrotal bladder hernias: a case series. Hernia. 2009; 13: 81-84.

5. Kraft KH, Sweeney S, Fink AS, et al. Inguinoscrotal bladder hernias: report of a series and review of the literature. Can Urol Assoc J. 2008; 2: 619-623.

6. Bjurlin MA, Delaurentis DA, Jordan MD, Richter HM. 3rdClinical and radiographic findings of a sliding inguinoscrotal hernia containing the urinary bladder. Hernia. 2010; 14: 635-638.