When the ureter slips: A rare case of ectopic uretero-inguinal hernia and its clinical implications

Abstract

Congenital anomalies like duplex renal collecting systems and ectopic ureters are rare. We report a unique case of a 61-year-old male presenting with left inguinal swelling, recurrent epididymo-orchitis, and LUTS. CT revealed a duplex collecting system with an ectopic ureter containing multiple calculi, terminating in the left inguinal region. The patient underwent laparoscopic ectopic ureterectomy and inguinal hernia repair. This case highlights the rare presentation of a uretero-inguinal hernia with an ectopic ureter containing multiple calculi inserting into the epididymis as its content. Laparoscopic management proved effective in treating this complex congenital urinary tract anomaly.

1 Introduction

An inguinal hernia is the protrusion of intraabdominal or extraperitoneal organs through an opening in the abdominal wall that is widely prevalent amongst males. Patients usually present with a swelling or pain in the inguinal region, with bowel, omentum or bladder usually being the content. A duplicated renal collecting system is a congenital anomaly occurring in 0.7–4 % of the population, while ectopic ureters are found in 1 in 2000–4000 individuals. In 80–85 % of cases, the ectopic ureter is associated with a duplicated renal collecting system. In males, ectopic ureters typically drain into structures derived from the mesonephric duct, including the epididymis, seminal vesicle, or vas deferens. However, the presence of a duplex collecting system with an ectopic ureter filled with multiple calculi as the content of an inguinal hernia is exceedingly rare and not reported in literature before. We present an unusual case of an adult male with an inguinal hernia containing an ectopic ureter that terminated in the epididymis, leading to recurrent epididymo-orchitis and urolithiasis.

2 Case report

A 61-year-old male with a history of diabetes mellitus presented with complaints of left inguinal swelling and recurrent left testicular pain associated with intermittent fever on and off for four years. He also reported dysuria and nocturia for the past six months. Physical examination ( Fig. 1 ) revealed a reducible left inguinal hernia with a stony hard structure palpable within the hernial sac and tenderness in the left testis.To evaluate the underlying pathology, an ultrasound of the kidneys, ureters, and bladder (KUB) was performed, followed by a contrast-enhanced computed tomography (CT) scan. Imaging revealed a left duplex collecting system, with the primary ureter draining normally into the bladder ( Fig. 2 A and B ). However, a secondary ectopic ureter measuring 3 cm in diameter, arising from the lower pole of the left kidney and containing multiple calculi (largest measuring 1.2 cm, 1372 HU), was found extending into the left inguinal region and terminating near the root of the scrotum.

The patient was scheduled for laparoscopic surgery. Intraoperative findings ( Fig. 3 A and B ) confirmed the distal end of the ectopic ureter inserting into the epididymis, with no functional communication to the bladder. The patient underwent laparoscopic left ectopic ureterectomy, left orchidectomy, and left inguinal hernia repair ( Fig. 3 C), specimen delivered through inguinal incision ( Fig. 4 ), and histopathological examination, reported as the presence of a blind-ending ectopic ureter terminating in the epididymis, along with multiple abscesses in the left testis. Post operative period was uneventful ( Fig. 5 ).