CASE REPORT Laparoscopic Repair of a Ureterosciatic Hernia with Urosepsis Kyong Tae Moon, Hee Ju Cho, Jae Duck Choi, Jung Yoon Kang, Tag Keun Yoo, Jeong Man Cho* Hernias of pelvic floor are very rare, and herniations of ureter into sciatic foramen are extremely rare condition which is globally reported only by 32 cases. Clinical aspects of ureterosciatic hernias appeared variously according to the degree of hydronephrosis, inflammation and infection of kidney due to ureter obstruction. Herein, we report our experience of laparoscopic repair in a patient with ureterosciatic hernia combined urosepsis. Keywords: laparoscopy; piriformis muscle; sciatic hernia; ureterosciatic hernia; urosepsis INTRODUCTION Sciatic hernias are the rarest entities among hernias of pelvic floor(1). Moreover, ureterosciatic hernias are very unusual lesions globally reported only by 32 cases; only 4 cases were reportedly repaired with laparoscopy(2-5). Here we repot a successful case of laparoscopic repair of ureterosciatic hernias with urosepsis. CASE REPORT Preoperative management and work up A 72-year-old female visited our hospital for right flank pain and fever lasting 2 days. She underwent contrast-en- hanced CT at the another hospital and was referred to our hospital for further evaluation and treatment. According to the laboratory results, leukocytosis, elevated CRP and pyuria were found. Based on outside CT, right perinephric infiltration and hydronephrosis were observed and the distal ureter was herniated to sciatic foramen (Figure 1a). Thus, we diagnosed and hospitalized the patient with urosepsis caused by ureterosciatic hernia, and operated per- cutaneous nephrostomy, immediately. After resolution of urosepsis, we decided to attempt correction of herniated ureter by retrograde approach. Retro- grade pyelography showed the right ureter was leant toward the outside of right side, and observe ‘’curlicue sign’’, which was formed as the knuckle of herniated ureter (Figure 1b). And then, we tried to insertion of flexible guide wire through the herniation site, but failed. Thus, we planned laparoscopic approach. Department of Urology, Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea. *Correspondence: Department of Urology, Eulji General Hospital, 68 Hangeulbiseong-ro, Nowon-gu, Seoul 139-872, Korea. TEL: +82-2-970-8306 FAX: +82-2-970-8517. E-mail: uro02@eulji.ac.kr. Received March 2018 & Accepted January 2019 Figure 1. A. Computed tomography showed herniation of Rt. ureter into sciatic foramen (arrow). B. Retrograde pyelography showed ‘’curlicue ureter’’ sign of ureterosciatic hernia (arrow). Urology Journal/Vol 16 No. 6/ November-December2019/ pp. 616-618. [DOI: 10.22037/uj.v0i0.4459] Operation management The patient was placed head down Rt. semi-lateral po- sition and then 12mm trocar for a camera was inserted at the level of umbilicus. And then one 12mm port and one 5mm port were placed under direct vision. After finding the ureter, dissection was performed to down- ward and the ureter was found to be herniated to the right sciatic foramen. As the herniated ureter was dis- sected from the sciatic foramen, the herniated ureter was repaired and curlicue appearance was gradually re- duced and disappeared (Figure 2). Then, the defect of right sciatic foramen was repaired with 3-0 PROLENE® by running sutures suturing the edges of the surround- ing connective tissue, and the operation was completed without ureteral stent placement. Postoperative follow-up The patient did not have any complications. At the 3rd day after the operation, we performed the AGP and obstruction was not found at the site of herniated ure- ter (Figure 3a). Then, percutaneous nephrostomy was removed. At the 10th day after the operation, we per- formed the DIP, and found the improvement of hydro- nephrosis and ureteral kinking (Figure 3b). DISCUSSION As the piriformis muscle occupies most of the greater sciatic foramen, organ of this site within pelvis would be herniated due to weakness and atrophy of piriformis muscle(6). Even though the sciatic hernias of various or- gans within pelvis were reported, ureterosciatic hernias are very unusual lesion globally reported only by 32 cases(2-5). The clinical aspects of ureterosciatic hernias appeared variously according to the degree of hydronephrosis, inflammation and infection of kidney(7). The ureteros- ciatic hernia can be diagnosed generally with excretory urography, the knuckle of herniated ureter was shown as typical ‘’curlicue sign’’(8). It can be also diagnosed through CT; the distal ureter was leant to the postero- lateral ischial spine and it was herniated to the sciatic foramen(9). Traditionally most of ureterosciatic hernias are repaired through open surgery. Since laparoscopic hernia repair was reported by Gee et al. in 1999, 4 cases of laparo- scopic ureterosciatic hernia repair have been report- ed(4,6,7,10). Laparoscopic repair of ureterosciatic hernia is relative simple procedure and it is a possible option for treatment. Unfortunately, long-term follow up has not been performed in our case, however there has been no report of complications or recurrence like as other pre- viously reported cases. REFERENCES 1. Losanoff JE, Basson MD, Gruber SA, Weaver DW. Sciatic hernia: a comprehensive review of the world literature (1900-2008). Am J Surg. 2010;199:52-9. 2. Loffroy R, Bry J, Guiu B, et al. Ureterosciatic hernia: a rare cause of ureteral obstruction visualized by multislice helical computed tomography. Urology. 2007;69:385.e1-3. 3. Rommel FM, Boline GB, Huffnagle HW. Ureterosciatic hernia: an anatomical radiographic correlation. J Urol. 1993;150:1232-4. 4. Tsuzaka Y, Saisu K, Tsuru N, Homma Y, Ihara H. Laparoscopic repair of a ureteric sciatic hernia: report of a case. Case Rep Urol. 2014;2014:787528. 5. Kato T, Komiya A, Ikeda R, Nakamura T, Akakura K. Minimally Invasive Endourological Techniques may Provide a Novel Method for Relieving Urinary Obstruction due to Ureterosciatic Herniation. Case Rep Nephrol Dial. 2015;5:13-9. 6. Gee J, Munson JL, Smith JJ, 3rd. Laparoscopic repair of ureterosciatic hernia. Urology. 1999;54:730-3. 7. Witney-Smith C, Undre S, Salter V, Al-Akraa M. An unusual case of a ureteric hernia into the sciatic foramen causing urinary sepsis: successfully treated laparoscopically. Ann R Coll Surg Engl. 2007;89:W10-2. 8. Beck WC, Baurys W, Brochu J, Morton Repair of a ureterosciatic hernia -Moon et al. Figure 2. Images from laparoscopic repair of an ureterosciatic hernia. A. The ureter herniated into sciatic foramen (arrow); B. After dissected from the sciatic foramen (arrow); C. Immediately reduced the ‘’curlicue’’ appearance (arrow); D. A small defect, sci- atic foramen was identified (arrow). Figure 3. A. Anterograde pyelography at postoperative day 3. There was no more obstruction on previous herniated site (arrow); B. Drip infusion pyelography (DIP) at postoperative day 10. Im- proved hydronephrosis and ureteral kinking. Vol 16 No 06 November-December2019 617 Case Report 618 WA. Herniation of the ureter into the sciatic foramen ("curlicue ureter"). J Am Med Assoc. 1952;149:441-2. 9. Arat A, Haliloglu M, Cila A, Demirkazik F, Balkanci F. Demonstration of ureterosciatic hernia with spiral CT. J Comput Assist Tomogr. 1996;20:816-8. 10. Whyburn JJ, Alizadeh A. Acute renal failure caused by bilateral ureteral herniation through the sciatic foramen. Urology. 2013;81:e38-9. Repair of a ureterosciatic hernia -Moon et al.