Surg TodayJpn J Surg (2000) 30:101–103

Urinary Bladder Injury During Inguinal Herniorrhaphy ina Renal Transplant Patient: Report of a Case

Shinya Kobayashi1, Tadashi Monma, Wataru Adachi, Shinji Nakata, Kazuhiro Yamaura,Jun Amano, Keiji Iizuka, Osamu Nishizawa, and Gengo Kaneko

Departments of 1 Surgery and 2 Urology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan3 Department of Surgery, Iida Municipal Hospital, 438 Yahata-machi, Iida 395-8502, Japan

A right inguinal hernia appeared 2 years after therenal transplantation. The size of the hernia sac gradu-ally increased. The hernia was located at the right in-guinal region, just caudal to the renal transplantationscar. The preoperative diagnosis was a right externalinguinal hernia. The hernia sac was fist-sized and thehernia contents were easily reducible.

In April 1997, a radical operation for right inguinalhernia was performed. First, the external inguinal ringwas incised. There was a muscle incision scar near theinguinal hernia. The muscle layers of the inguinal regionwere thin, and the spermatic cord firmly adhered tothe surrounding tissue. Two sacs were detected in theoperation field (Fig. 1). The lateral sac (A) seemed tobe an indirect inguinal hernia and the median sac (B;urinary bladder in reality) a direct inguinal hernia. Asthe hernia orifice of A was large, a purse-string suturewas performed to close the orifice after resecting thehernia sac. B was small, so a transfixing suture wasperformed to achieve closure after resecting the herniasac (urinary bladder in reality). The posterior wall ofthe inguinal canal was repaired by the procedure ofMcVay’s.6 A histological examination of the removedspecimen of B showed it to be the wall of the bladder.Using a non-absorbable material to close the bladderis likely to result in a foreign-body reaction and thuscause infection. As a result, a second operation wasimmediately performed.

The bladder was reopened, and 20mg Indigocarminewas administered intravenously in one injection. Noleakage of urine from the ureter and extravasation ofurine in the bladder was observed. The bladder wasclosed with two layers by means of running and inter-rupted sutures using absorbable suture material. Theposterior wall of the inguinal canal was too weak to besutured this time, so a tension-free method usingMarlex-mesh was used.7

The white blood cell and C-reactive protein levelswere elevated temporarily after the operation but were

Abstract: The urinary bladder was injured in a renal trans-plant patient during inguinal herniorrhaphy. The bladder wasmistakenly identified as an internal inguinal hernia. The pro-tuberant bladder from the thin muscle layers was caused bya previous renal transplantation. The defect in the bladderwas sutured by absorbable suture material, and the posteriorwall of the inguinal canal was reinforced by artificial mesh.Surgeons performing inguinal herniorrhaphy on the graftedside in a renal transplant patient should thus be warned notto injure the bladder during the operation.

Key Words: renal transplantation, inguinal hernia, bladder,complications

Introduction

There are many urological complications that occur inrenal transplantation,1–5 and most cases occur soon aftertransplantation. However, urinary bladder injury ininguinal herniorrhaphy of a renal transplant patient hasnot been previously reported.

Case Report

A 39-year-old Japanese man was the recipient of aliving related renal transplant in 1993. The kidney wasengrafted in the right iliac fossa using end-to-end anas-tomosis between the renal artery and the internal iliacartery, and end-to-side anastomosis between the renalvein and the external iliac vein. The ureter was im-planted within the bladder using a standard Paquin-Marshall ureterocystostomy.

Reprint requests to: S. Kobayashi(Received for publication on Sept. 17, 1998; accepted on July13, 1999)

102 S. Kobayashi et al.: Inguinal Herniorrhaphy in Transplant Patient

reduced to within the normal limits by the eighth post-operative day (Fig. 2). The patients recovery wassmooth and uneventful.

Discussion

Various urological complications have been reported tooccur as a complication of herniorrhaphy. The bladderand testicular artery are at risk of injury during routineherniorrhaphy. In pediatric patients, the bladder can bemistakenly identified as a hernia sac during herniorrha-phy. Among renal transplant patients, reports of uro-logical complications during inguinal herniorrhaphy arerare. Although Selman et al.8 has reported a ureteralligation following inguinal herniorrhaphy in a trans-plant patient, bladder injury has not been reported. Inthis case, the thin muscle layers of the inguinal regionwere due to a muscle incision located near the inguinalcanal from the previous renal transplantation. Both theexternal inguinal hernia and the protuberant bladderwere caused by these weak muscle layers. The protuber-ant urinary bladder was a kind of incisional hernia. Theincision for renal transplantation should not be near theinguinal canal so as to avoid an external inguinal hernia

Fig. 1. The lateral sac (A) seemed to be an indirect inguinalhernia and the median sac (B) a direct inguinal hernia (urinarybladder in reality)

Fig. 2. Changes in the white blood cell (WBC, open circles)and C-reactive protein (CRP, closed circles) levels after theoperation. POD, postoperative day

and/or an incisional hernia. When inguinal herniorrha-phy is performed on renal transplant patients, surgeonsshould therefore be aware of the possibility of anadhered bladder.

Our experience has revealed several measures whichcan help to prevent injury to the urinary bladder, includ-ing (1) preoperative cystography and (2) careful proce-dures during the operation. If the bladder is injured, (1)the leak of any urine should be immediately confirmedusing dye and (2) absorbable suture materials should beused to close the muscle layers of the bladder to wardoff any foreign-body reaction and infection.

In this case, artificial mesh was used to repair theindirect inguinal hernia as a tension-free method atthe second operation. The postoperative course wassmooth and no infection occurred. Artificial mesh wasthus shown to be safe for a renal transplant patienttaking immunosuppressive drugs.

This case emphasizes the need for accurate knowl-edge of the special anatomical problems of renaltransplant patients.

References

1. Hakim NS, Benedetti E, Pirenne J, Gillingham KJ, Payne WD,Dunn DL, Sutherland DER, Gruessner R, Gores PF, Matas AJ,Najarian JS (1994) Complications of ureterovesical anastomosisin kidney transplant patients: the Minnesota experience. ClinTransplant 8:504–507

2. Rigg KM, Proud G, Taylor RM (1994) Urological compli-cations following renal transplantation. A study of 1016 consecu-tive transplants from a single centre. Transplant Int 7:120–126

3. Mundy AR, Podesta ML, Bewick M, Rudge CJ, Ellis FG (1981)The urological complications of 1000 renal transplantations. Br JUrol 53:397–402

4. Palmer JM, Chatterjee SN (1978) Urologic complications in renaltransplantation. Surg Clin N Am 58:305–319

5. Ehrlich RM, Smith RB (1977) Surgical complications of renaltransplantation. Urology 10:43

6. McVay CB (1948) Inguinal and femoral hernioplasty: anatomicrepair. Arch Surg 57:524–530

7. Lichtenstein IL, Shore JM (1986) Ambulatory outpatient surgery.Including a new concept, introducing tension-free repair. Int Surg71:1–4

8. Selman SH, Grecos GP, Koo BC (1984) Anuria in transplantpatient following inguinal herniorrhaphy. J Urol 133:669–670

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