Letter to the Editor
Ureteral hernia into the greater sciatic foramen treated by ureteral stent placement
Hernia ureteral a través de orificio ciático mayor tratada mediante colocación de catéter ureteral
M. Rodríguez Cabero
, G. Arnal Chacón
Corresponding author
Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Rodríguez Cabero, G. Arnal Chacón" "autores" => array:2 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Rodríguez Cabero" "email" => array:1 [ 0 => "mrcabero@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Arnal Chacón" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hernia ureteral a través de orificio ciático mayor tratada mediante colocación de catéter ureteral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 844 "Ancho" => 1305 "Tamanyo" => 190291 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT showing change of caliber in the left distal ureter, passing through the greater sciatic foramen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ureteral hernia is a rare condition with few cases described in the literature.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Clinically, as it can present with a wide range of symptoms, CT is a very useful tool for its diagnosis. Management by retrograde ureteral stenting has been described,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> with possible recurrence after subsequent stent removal.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of an 81-year-old woman with a history of hypertension and treatment with enalapril. She presented to the emergency department with left iliac fossa pain associated with nausea, vomiting and voiding syndrome. Laboratory tests showed leukocytosis with neutrophilia, without renal function impairment.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In face of suspected renal/ureteral colic, contrast-enhanced CT was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), showing a change in the caliber of the distal third of the left ureter, which follows a path through the greater sciatic foramen distal to the intersection with the iliac vessels, consistent with ureteral hernia into the greater sciatic orifice. Ipsilateral retrograde ureteropelvicalyceal dilatation, with perirenal fluid bands.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In view of these findings, a left double J stent was inserted. Retrograde pyelogram was performed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) with the contrast agent remaining from the previously performed CT, showing curlicue formation of the distal ureter and poor contrast uptake. The guidewire was advanced into the pelvis and the ureteral stent was passed beyond the loop to straighten the ureter, and the double J was easily inserted.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient evolved favorably and was discharged with a double J stent (subsequently removed) without presenting new clinical manifestations to date.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Ureteral hernia is a rare condition, generally occurring at the inguinal, scrotal or femoral level. Ureteral hernias into the sciatic foramen are extremely rare, with less than 40 cases described in the literature.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The piriformis muscle divides the foramen into suprapiriformis and infrapiriformis compartments and ureterosciatic herniation usually occurs in the suprapiriform space of the greater sciatic foramen. Predisposing factors are muscle atrophy, abdominal wall defects, congenital anomalies or neuromuscular disorders. Involvement of the left ureter is generally more common, and the condition is more frequent in older women.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinically, it presents with a wide range of symptoms; patients can be asymptomatic or present abdominal pain or renal colic.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Diagnosis is based on radiological tests, mainly CT, which is able to diagnose the ectopic location of the ureter and provide anatomical information as well.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Surgical management is described in the literature, most recently by laparoscopic or robotic approach. However, treatment is only recommended in symptomatic cases or when less invasive management fails.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In older patients or poor surgical candidates, several cases of endoscopic management by retrograde ureteral stent placement have been described with successful hernia reduction.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Recurrences have been reported after stent removal, but in most cases, patients remain asymptomatic without the need for more aggressive management.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">This work has not received any funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez Cabero M, Arnal Chacón G. 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Actas Urol Esp. 2021;45:564–565.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 844 "Ancho" => 1305 "Tamanyo" => 190291 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT showing change of caliber in the left distal ureter, passing through the greater sciatic foramen.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1815 "Ancho" => 905 "Tamanyo" => 188968 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pyelogram showing double J stent placement.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ureterosciatic hernia: an up-to-date overview of evaluation and management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Gandhi" 1 => "M.Y. Lee" 2 => "G. Joshi" 3 => "N.L. Smith" 4 => "S.A. Khan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.tria.2018.04.002" "Revista" => array:5 [ "tituloSerie" => "Trans Res Anatomy" "fecha" => "2018" "volumen" => "11" "paginaInicial" => "5" "paginaFinal" => "9" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of ureterosciatic hernia with a ureteral stent" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K. Yanagi" 1 => "A. Kan" 2 => "T. Sejima" 3 => "A. 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