








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Urinary bladder neoplasms, postoperative 
complications, internal hernia, cystectomy

None declared.

Patient consent: Obtained.

Received on May 2, 2022 
Accepted on, May 9, 2022

Soc Int Urol J. 2023;4(1):71–72

DOI: 10.48083/ZJNE2733

Incarcerated Internal Hernia Posterior to the Iliac 
Vessels After Uncomplicated Radical Cystectomy

Sydney Sparanese, Cyrus Chehroudi, Peter C. Black

Department of Urologic Sciences, University of British Columbia, Vancouver, Canada

Radical cystectomy (RC) with pelvic lymph node 
dissection (PLND) remains the standard of care for 
patients with muscle-invasive bladder cancer[1]. Despite 
improvements in surgical technique and perioperative 
care, complications of any grade occur in up to 58% of 
patients after RC, with infectious and genitourinary 
complaints being the most common[2]. We present a 
clinical picture of a rare complication: an incarcerated 
internal hernia of the small bowel behind the external 
iliac artery after an uncomplicated RC, PLND, and ileal 
conduit in a 77-year-old male. 

The patient presented to a community hospital with a 
2-day history of recurrent episodes of nausea, vomiting, 
and non-specific, crampy abdominal pain 6 weeks after 
RC. His abdomen was tender on examination, but there 
was no sign of peritonitis. Bloodwork revealed mild 
leukocytosis and an abdominal computed tomography 
(CT) demonstrated no specific cause for his symptoms. 

A repeat CT 4 days later demonstrated abrupt termi-
nation of oral contrast in the right hemipelvis, imme-
diately adjacent to the external iliac artery (Figure 1, 
left). Edematous small bowel was trapped posterior and 
inferior to the iliac artery, consistent with internal herni-
ation. At this point, the patient had signs of peritonitis 
with rebound tenderness. 

The patient underwent emergent laparotomy. The 
intraoperative findings confirmed small bowel obstruc-
tion secondary to entrapment of the bowel behind the 
right external iliac artery that had been skeletonized by 
prior PLND (Figure 1, right). The bowel was gangre-
nous and required resection. A re-look laparotomy was 
performed 2 days later with restoration of intestinal 
continuity. One week following his final procedure, the 
patient was transferred to a community hospital near his 
home in stable condition, and he made a full recovery. 

References

1. Gakis G, Efstathiou J, Lerner SP, Cookson MS, Keegan KA, Guru KA, 
et al. ICUD-EAU International Consultation on Bladder Cancer 2012: 
Radical Cystectomy and Bladder Preservation for Muscle-Invasive 
Urothelial Carcinoma of the Bladder. Eur Urol.2013 Jan 1;63(1):45–57. 

2. Hautmann RE, De Petriconi RC, Volkmer BG. Lessons learned from 
1,000 neobladders: The 90-day complication rate. J Urol.2010 
Sep;184(3):990–994. doi/abs/10.1016/j.juro.2010.05.037

71SIUJ.ORG SIUJ  •  Volume 4, Number 1  •  January 2023

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FIGURE 1.  
Incarcerated internal hernia of the small intestine. Both the computed tomography (left panel) and the 
intraoperative photograph (right panel) show the gangrenous ileum (marked with star) trapped below the 
right external iliac artery (outlined with white lines). The point where the ileum traverses posterior to the 
artery is marked with the block arrow and the dilated small bowel proximal to this is marked with a triangle. 
The resected small bowel is shown in the inset.

72 SIUJ  •  Volume 4, Number 1  •  January 2023 SIUJ.ORG

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