Retro-ureteral Small Bowel Herniation After Radical Cystectomy.

Small bowel obstruction caused by internal herniation under ureteric bands is a rare occurrence. Only 6 previous cases have been documented. This case report reviews the case of a 79-year-old male who presented to emergency with abdominal pain requiring subsequent laparotomy and release of internal herniation of bowel under ureter.

A 79-year-old male presented to the emergency department of a tertiary hospital 12-days post radical cystectomy and ileal conduit formation with complaints of sudden onset abdominal pain with associated nausea and vomiting. He had experienced 4 h of severe generalised abdominal and rectal pain that commenced after opening his bowels that morning.

The patient had undergone a cystectomy and ileal conduit formation for definitive treatment of transitional cell carcinoma with the standard passing of the left ureter through the base of the sigmoid mesentery across to the ileal conduit. His recovery had been unremarkable until the day of presentation.

Other significant medical history included ischemic heart disease with acute myocardial infarction (1989), hyperlipidaemia, bilateral inguinal hernia repairs (2011, 2012), a recent episode of supraventricular tachycardia requiring inpatient management with sotalol and pulmonary embolism (2013) requiring long term warfarinisation.

Physical examination revealed a mildly tender left lower quadrant with voluntary guarding. Laboratory examinations showed an elevated white cell count (11.3 × 109/L) and C-reactive protein (84 mg/L). An abdominal and pelvic CT scan was performed that revealed several fluid filled distended loops of small bowel with two identified transition points consistent with a closed loop small bowel obstruction (SBO) (Fig. 1).

Figure 1

“LEFT: Coronal section of the abdominal and pelvic CT demonstrating transition point (marked by arrow) of the bowel. RIGHT: Axial section of pelvic CT demonstrating narrowing of the bowel.”

The patient underwent an exploratory laparotomy. Approximately 1 m of small bowel had herniated under the left ureter with signs suggestive of incarceration (Fig. 2). The bowel was gently manipulated from underneath the left ureter to its original position. The loop of strangulated bowel was slightly injected post reduction but remained viable throughout (Fig. 3). The left ureter remained healthy and viable and omentum was imbricated over the ureter to prevent further herniation.

Figure 2

“1 m loop of small bowel herniated under the left ureter. Left ureter = white arrow, incarcerated bowel = black arrow.”

Figure 3

“Signs of mild injection in the bowel after reduction from underneath the left ureter.”

The patient was admitted to the intensive care unit. On the second day he passed flatus and his nasogastric tube was removed. He was discharged on the seventh post-operative day without further complication.

Small bowel obstruction caused by internal herniation under ureteric bands is a rare occurrence. Only six previous cases of retro-ureteral internal herniation have been documented.1, 2, 3, 4, 5 Of the six previous cases, only one case occurred after primary urological surgery (ureteric reimplantation for vesicoureteric reflux) while all other documented cases occurred after gynaecological procedures.1, 2, 3, 4 There are no published cases of SBO caused by an internal herniation of the small bowel under a ureter following cystectomy and ileal conduit formation.

This unusual cause of small bowel obstruction occurring two weeks following cystectomy highlights the possibility of a transperitoneal ureter causing small bowel obstruction. A CT scan showing a closed loop obstruction in the setting of a urinary diversion should raise the suspicion of a ureteric band obstruction which can be rapidly corrected with surgical intervention.

Conflict of interest

There is no conflict of interest.