Nephroptosis and ureteroinguinal incarcerated hernia mimicking acute appendicitis

Nephroptosis and ureteroinguinal incarcerated hernia mimicking acute appendicitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Nephroptosis and ureteroinguinal incarcerated hernia mimicking acute appendicitis Michal Gergel, Ivan Brychta, Anita Lancz-Klikacova, Alexander Mayer This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4417905/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Jul, 2024 Read the published version in BMC Urology → Version 1 posted 18 You are reading this latest preprint version Abstract The involvement of kidney, perirenal fat, and ureter is a rare variant of inguinal hernia. We report a case of a 78-year-old man presenting with typical clinical signs of acute appendicitis. Ultrasonography and CT scan revealed ptosis of the right kidney with a major part of the perirenal capsule involved in a large right sided inguinal hernia with acute obstruction of the ureter and urostasis. Acute surgery was performed, involving resection of perirenal fat, liberation, resection, and neoimplantation of the ureter, and hernioplasty. The postoperative period was uneventful. This case illustrates diagnostic unpredictability of acute appendicitis as well as anatomic variety of inguinal hernias. ureteroinguinal hernia acute appendicitis ureteral incarceration Figures Figure 1 Figure 2 Figure 3 Introduction The inguinal hernia and its complications represent a common condition routinely treated by general surgeons worldwide; however, a large spectrum of clinical and anatomical variabilities can turn a routine inguinal hernia into a surgical challenge. Ureteroinguinal hernias in patients with native kidneys are rare with only approximately 180 cases reported so far ( 1 , 2 , 3 ). The involvement of the ureter in an inguinal hernia can be a surprise finding during a planned hernia surgery with a high risk of recognized or unrecognized ureteral injury. Other cases were diagnosed following the differential diagnosis of obstructive uropathy or obstructive pyelonephritis. The herniation of perirenal fat may be associated with ureteral hernias, as well ( 4 ). A specific form of ureteroinguinal hernia involves the kidney – either ectopic or ptotic. The complete herniation and incarceration of the kidney in an inguinal hernia has been described as an extremely rare finding ( 5 , 6 ). Pyelonephritis of an ectopic or ptotic right kidney has also been described as a cause of right lower quadrant pain, making it an extremely rare differential diagnosis when considering acute appendicitis. ( 7 , 8 , 9 ). Imaging by ultrasonography and/or CT would reveal this unexpected condition with almost absolute accuracy, but these imaging techniques are not routinely utilized, either because of clear clinical findings or because of their unavailability. The combination of ureteroinguinal hernia with an acute incarceration of the ureter with ptotic right kidney mimicking acute appendicitis has, to our knowledge, not yet been described. Case report A 78-year-old Caucasian male (175 cm, 85 kg, BMI 27.7 kg/m2) being treated chronically for arterial hypertension and neuropathy, with a past surgical history of bilateral hip arthroplasty, reported to the emergency department with acute abdominal pain. The pain began the previous day and worsened gradually over 32 hours, starting as diffuse abdominal pain that migrated to the right lower quadrant with radiation to the lumbar region. Other than anorexia, no gastrointestinal symptoms were present. The patient also reported the presence of a right inguinal hernia, which he had been aware of for 5 years; however, he had not considered surgery due to inconvenience. Additionally, the abdominal pain was not associated with any local changes to the hernia or pain related to the hernia. Physical examination showed localized pain in the right lower quadrant with local tenderness. Both Bloomberg and Pleniés signs were positive, while the Rovsing sign and rectal examination were negative. There was a right sided inguinal hernia with a large irreducible sac reaching deep into scrotum (approximately 15x7cm). The sac was slightly painful; however, typical signs of incarceration were absent. Laboratory findings showed significant inflammatory activity: CRP 293 mg/l, leucocyte count 21500/µl. Our first line diagnosis, considering typical current complaints and clinical findings, was acute appendicitis. Nevertheless, we considered complications related to the large inguinal hernia, as well. As a result, we requested abdominal ultrasonography. Surprisingly, it showed a medially located cecum with no signs of appendicitis and an ectopic right kidney located in the right hypogastrium with slight dilation of the pelvis, calices, and proximal ureter. The point of maximal pain was clearly located at the kidney. Following this unexpected finding, we performed a CT scan, which showed the right ptotic kidney located in the right iliac fossa, with grade 2 to 3 renal stasis. (Fig. 1 ) The renal artery and vein were stretched from their normal anatomic origin caudally towards the descended kidney hilum. Renal perfusion in both arterial and venous phases of the scan was normal. The right renal capsule was almost completely dislocated in the inguinal hernia. The ureter was proximally dilated to 15mm and was headed towards the inguinal hernia with apparent constriction in the hernia neck. Considering these findings, we concluded the final diagnosis of a sliding right inguinal hernia containing the capsule of the right kidney with acute obstruction (incarceration) of the right ureter. Painful palpation of the right kidney along with elevated inflammatory markers strongly indicated acute obstructive pyelonephritis, although urinalysis showed completely negative results. Due to the risk of ischemic damage to the right kidney and the ureter, as well as risk of urosepsis, we initiated empiric antibiotic therapy with ceftizoxime and recommended urgent surgery. Surgery was performed under general anesthesia. A foley urinary catheter was inserted, and the urinary bladder was filled with 50ml normal saline. Through a standard inguinal incision, the external ring was visualized, and the hernia content was extracted from the right hemiscrotum revealing well bordered fatty tissue with a fibrous capsule. After the incision of the anterior wall of the inguinal channel, we identified an epigastric artery located medial to the hernia neck, confirming an anatomically indirect hernia. The spermatic cord was identified dorso-medially to the neck and isolated. Throughout the preparation of the hernia content, no peritoneal structures were involved. The ureter was located in the medial proximal part of the hernia and was pulled to the external orifice with significant dilatation of the proximal half. There were no signs of ischemia, and shortly after liberation, typical ureteral peristalsis was present. After the incision of the frontal wall of the fibroadipose tissue in the external inguinal ring, the inferior pole of the right kidney was revealed as part of the content of the hernia neck heading towards the hernia. Despite this, there were no signs of mechanical damage to the visible part of the kidney. After the complete separation of the ureter and manual repositioning of the kidney cranially, no other anatomical structures were found in the hernia neck. Almost the whole perirenal fat capsule, which was contained in the hernia, was completely resected at the level of inferior renal pole. (Fig. 2 , Fig. 3 ) The whole formation measured 23x10x6cm and weighed 850g. The right ureter was approximately 30cm long, and, as the kidney was dislocated in the right iliac fossa, the direct distance from the inferior pole to the urinary bladder was reduced to approximately 5cm. The ureter was, therefore, extremely crooked and prone to future kinking. As a result, we resected a 10 cm segment, ligated the distal part, and implanted the proximal segment to the bladder wall with a JJ stent. A sample for microbiology was taken from the ureter. A Redon drain was placed in the space of Retzi to control possible urinary leak. Finally, we performed a Liechtenstein hernioplasty using polypropylene mesh 10x15cm for definitive treatment of the inguinal hernia. Perioperative microbiology showed sterile findings from the ureteral sample. The postoperative period was uneventful consisting of slight hematuria and satisfactory reduction of inflammatory parameters. Renal parameters showed no significant pathology. The urinary catheter was removed after 4 days, and the patient was discharged for outpatient treatment. The JJ stent was removed 6 weeks after the procedure. Discussion The clinical symptoms of our patient were typical for acute appendicitis with no complaints of hernia changes or dysuria. Physical examination showed no specific findings of incarceration, and the kidney was not palpable due to central obesity. Many experienced surgeons rely on clinical findings to diagnose acute appendicitis, subsequently referring these patients for appendectomy. Although we do not consider ultrasonography a necessary measure, we request it in all clinically unclear cases, as well as in elderly patients. Our case suggests that ultrasonography should be considered a routine method if it is available. The CT scan showed obstruction of the right ureter and acute hydronephrosis. Acute obstructive pyelonephritis was very likely,considering significant elevation of inflammatory markers. We considered less invasive options, such as ureteral perturbation and percutaneous nephrostomy. Ureteral perturbation was likely to fail due to kinking of the ureter. While nephrostomy was easily achievable, only surgery was capable of providing definitive treatment. The normal anatomical position of the kidney is stabilized by the perirenal fat and fascias. The sliding of this fat capsule towards the inguinal channel and further to the inguinal hernia caused instability of the kidney position and its descent into the right iliac fossa and further towards the inguinal channel. The lack of any specific symptoms, apart from the apparent inguinal hernia, suggests that the process of descent was gradual. The right kidney was thoroughly examined with no signs of ischemia or other pathology. Resection of perirenal fat, shortening of the ureter, and hernia repair appear to be sufficient measures to stabilize the position of the kidney and maintain its full function. Liberating the ureter from the hernia may be sufficient for the treatment of urinary obstruction; however, significant descent of the kidney increased risk of future ureteral kinking. At this point, resection of the ureter and neoimplantation was considered to be the best option. Conclusion An inguinoscrotal hernia involving the perirenal fat capsule and ureter (ureteroinguinal hernia) is a rare condition with variable clinical presentations. It is associated with nephroptosis and may cause acute kidney obstruction and possible obstructive pyelonephritis. The clinical presentation in such a situation can persuasively mimic acute appendicitis. Ultrasonography and/or CT may not necessarily be performed in clinically clear cases of acute appendicitis; however, it is highly advisable to request further imaging when atypical local changes, e.g. inguinal hernia, are present. Abbreviations CT – computer tomography US – ultrasound BMI – body mass index Declarations Funding : none Data availability : all original data are included in patient´s medical records and internal medical database of University Hospital Bratislava. All data generated or analysed during this study are included in this published article Ethics approval: not applicable Consent to participate has been obtained in Slovak language and are included in patient´s file Consent for publication : Patient gave written informed consent for their personal or clinical details along with any identifying images to be published in this study. Authors' contributions : Michal Gergel : managed the patient and conducted described surgery, wrote the manuscript; Ivan Brychta: supervised patient management and assisted with writing of the manuscript; Anita Lancz-Klikacova: prepared figures, assisted with literature research, did the outpatient follow-up; Alexander Mayer: supervised manuscript finalisation and literature research Acknowledgements : none Competing interest : none References Turner A, Subramanian P. “Ureteroinguinal Hernia: A Rare General Surgery Phenomenon.:” Cureus (2021): e20586. DOI: 10.7759/cureus.20586 Ahmed S, Stanford R. “Ureteric obstruction secondary to a paraperitoneal inguinal hernia.” Ann R CollSurg Engl. (2016): e16-e18. doi: 10.1308/rcsann.2016.0024. Beebe K, Muhonen J, Giuseppucci P, Esper C. “A Rare Case of an Inguinal Hernia-Containing (Extraperitoneal) Ureter.” Am J Case Rep. 2021; e930911-1–e930911-5; doi: 10.12659/AJCR.930911 Osmani HT, Boulton R, Wyatt H, Saunders SM. “An unusual inguinoscrotal hernia with renal involvement.” BMJ Case Rep. (2015): bcr2015211519; DOI: 10.1136/bcr-2015-211519 Shchukin D, Demchenko V, Arkatov A, Stetsyshyn R, Khareba G, Bielov V. “"Extreme Nephroptosis": A Kidney in the Inguinal Hernia.” Case Rep Med. (2023); DOI: 10.1155/2023/1439919 Kim J, Harper B, Turner A, Gonzalez IA, Andrade A. “Incarcerated native orthotopic kidney through an inguinal hernia: A case report and literature review.” J Surg Case Rep. (2023): rjad378; doi: 10.1093/jscr/rjad37 Lossius MN, Araya CE, Henry DD, Neiberger RE. “A patient with an unusual cause right lower quadrant pain and vomiting: pyelonephritis of an ectopic right kidney masquerading as acute appendicitis.” Case Rep Med. (2009): 638501; doi: 10.1155/ 2009 /638501 Manglik A, Tomar L, Akash A. “Pyelonephritis of an ectopic right kidney pretending as acute appendicitis: An unusual case.” Int J Surg Case Rep (2022): 107490. DOI: 10.1016/j.ijscr.2022.107490 Xu YE, Hendahewa R. “A rare presentation of an ectopic kidney with pyelonephritis mimicking appendicitis.” J Surg Case Rep. (2019): rjz342; DOI: 10.1093/jscr/rjz342 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 29 Jul, 2024 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 21 Jun, 2024 Reviews received at journal 20 Jun, 2024 Reviewers agreed at journal 20 Jun, 2024 Reviews received at journal 19 Jun, 2024 Reviews received at journal 19 Jun, 2024 Reviewers agreed at journal 18 Jun, 2024 Reviews received at journal 17 Jun, 2024 Reviewers agreed at journal 17 Jun, 2024 Reviewers agreed at journal 17 Jun, 2024 Reviewers agreed at journal 16 Jun, 2024 Reviewers agreed at journal 16 Jun, 2024 Reviews received at journal 15 Jun, 2024 Reviewers agreed at journal 15 Jun, 2024 Reviewers invited by journal 13 Jun, 2024 Editor invited by journal 10 Jun, 2024 Editor assigned by journal 10 Jun, 2024 Submission checks completed at journal 10 Jun, 2024 First submitted to journal 14 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4417905","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":317220769,"identity":"6a5a24f8-f2f6-4b78-980f-41dac0c33c3e","order_by":0,"name":"Michal Gergel","email":"","orcid":"","institution":"University Hospital Bratislava","correspondingAuthor":false,"prefix":"","firstName":"Michal","middleName":"","lastName":"Gergel","suffix":""},{"id":317220771,"identity":"5f782de7-680c-4ade-b350-bb467f493e74","order_by":1,"name":"Ivan Brychta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYBACNiBmBjEMGBgYHwBpHj7itbAxMBuAtLARYxNMC5sEzBC8gE8i+dnjwj2H5c3lm59Vfs2xkwHa9vDRDXwOk0gzN57x7LDhzjY2s9uy25KBDmMzNs7Bp4XngJk0z4HDCQbHGMxuS25jBmrhYZPGr+X4N6gW9m/FktvqidDC3gOzhceM8eO2w0RpKZOecSDdcMOxnGJpxm3HediYCfhFvpl9m3TBAWt5g8PHN378ua3anp+9+eFjfFqgoBlMMvOAScLKQaAOTDL+IE71KBgFo2AUjDAAAHqeQGwP5pYPAAAAAElFTkSuQmCC","orcid":"","institution":"Slovak Medical University","correspondingAuthor":true,"prefix":"","firstName":"Ivan","middleName":"","lastName":"Brychta","suffix":""},{"id":317220773,"identity":"5be910bd-b342-4f93-87aa-68060bd6d310","order_by":2,"name":"Anita Lancz-Klikacova","email":"","orcid":"","institution":"University Hospital Bratislava","correspondingAuthor":false,"prefix":"","firstName":"Anita","middleName":"","lastName":"Lancz-Klikacova","suffix":""},{"id":317220775,"identity":"287395a5-6dbb-4cb9-acf5-05586a76ef18","order_by":3,"name":"Alexander Mayer","email":"","orcid":"","institution":"University Hospital Bratislava","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Mayer","suffix":""}],"badges":[],"createdAt":"2024-05-14 09:03:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4417905/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4417905/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-024-01549-x","type":"published","date":"2024-07-29T15:57:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59514669,"identity":"de7b46f7-e4ed-4721-8a97-a155c38c61b2","added_by":"auto","created_at":"2024-07-02 17:27:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":556226,"visible":true,"origin":"","legend":"\u003cp\u003e3D reconstruction of CT scan, showing ptotic right kidney with normal origin of renal vessels and ureter obstructed in inguinal ring.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4417905/v1/8c2a3a9186488c920e582a5b.png"},{"id":59514671,"identity":"06f99abb-c43c-4e24-934a-6237901e291b","added_by":"auto","created_at":"2024-07-02 17:27:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1398283,"visible":true,"origin":"","legend":"\u003cp\u003eInguinal hernia containing perirenal fat (A) and dilated ureter (B).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4417905/v1/06cbc0ff09b72203a1e7f9b2.png"},{"id":59514670,"identity":"a62a82d2-eb2d-4f3a-8595-109e1058f0e4","added_by":"auto","created_at":"2024-07-02 17:27:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2910551,"visible":true,"origin":"","legend":"\u003cp\u003eInferior pole of the right kidney (A) visible in the internal inguinal ring (B) with perirenal fat (C) involved in the inguinal hernia.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4417905/v1/80a3ae5cab147f260cb2b1cf.png"},{"id":61793824,"identity":"a4c5983a-29c9-41f9-b45b-b09ffc901f44","added_by":"auto","created_at":"2024-08-05 16:15:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9180095,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4417905/v1/c824a274-31ad-4844-8c23-c371757ddbf1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nephroptosis and ureteroinguinal incarcerated hernia mimicking acute appendicitis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe inguinal hernia and its complications represent a common condition routinely treated by general surgeons worldwide; however, a large spectrum of clinical and anatomical variabilities can turn a routine inguinal hernia into a surgical challenge. Ureteroinguinal hernias in patients with native kidneys are rare with only approximately 180 cases reported so far (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The involvement of the ureter in an inguinal hernia can be a surprise finding during a planned hernia surgery with a high risk of recognized or unrecognized ureteral injury. Other cases were diagnosed following the differential diagnosis of obstructive uropathy or obstructive pyelonephritis. The herniation of perirenal fat may be associated with ureteral hernias, as well (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A specific form of ureteroinguinal hernia involves the kidney – either ectopic or ptotic. The complete herniation and incarceration of the kidney in an inguinal hernia has been described as an extremely rare finding (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePyelonephritis of an ectopic or ptotic right kidney has also been described as a cause of right lower quadrant pain, making it an extremely rare differential diagnosis when considering acute appendicitis. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Imaging by ultrasonography and/or CT would reveal this unexpected condition with almost absolute accuracy, but these imaging techniques are not routinely utilized, either because of clear clinical findings or because of their unavailability. The combination of ureteroinguinal hernia with an acute incarceration of the ureter with ptotic right kidney mimicking acute appendicitis has, to our knowledge, not yet been described.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Case report","content":"\u003cp\u003eA 78-year-old Caucasian male (175 cm, 85 kg, BMI 27.7 kg/m2) being treated chronically for arterial hypertension and neuropathy, with a past surgical history of bilateral hip arthroplasty, reported to the emergency department with acute abdominal pain. The pain began the previous day and worsened gradually over 32 hours, starting as diffuse abdominal pain that migrated to the right lower quadrant with radiation to the lumbar region. Other than anorexia, no gastrointestinal symptoms were present. The patient also reported the presence of a right inguinal hernia, which he had been aware of for 5 years; however, he had not considered surgery due to inconvenience. Additionally, the abdominal pain was not associated with any local changes to the hernia or pain related to the hernia.\u003c/p\u003e\n\u003cp\u003ePhysical examination showed localized pain in the right lower quadrant with local tenderness. Both Bloomberg and Pleni\u0026eacute;s signs were positive, while the Rovsing sign and rectal examination were negative. There was a right sided inguinal hernia with a large irreducible sac reaching deep into scrotum (approximately 15x7cm). The sac was slightly painful; however, typical signs of incarceration were absent.\u003c/p\u003e\n\u003cp\u003eLaboratory findings showed significant inflammatory activity: CRP 293 mg/l, leucocyte count 21500/\u0026micro;l. Our first line diagnosis, considering typical current complaints and clinical findings, was acute appendicitis. Nevertheless, we considered complications related to the large inguinal hernia, as well. As a result, we requested abdominal ultrasonography. Surprisingly, it showed a medially located cecum with no signs of appendicitis and an ectopic right kidney located in the right hypogastrium with slight dilation of the pelvis, calices, and proximal ureter. The point of maximal pain was clearly located at the kidney. Following this unexpected finding, we performed a CT scan, which showed the right ptotic kidney located in the right iliac fossa, with grade 2 to 3 renal stasis. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) The renal artery and vein were stretched from their normal anatomic origin caudally towards the descended kidney hilum. Renal perfusion in both arterial and venous phases of the scan was normal. The right renal capsule was almost completely dislocated in the inguinal hernia. The ureter was proximally dilated to 15mm and was headed towards the inguinal hernia with apparent constriction in the hernia neck. Considering these findings, we concluded the final diagnosis of a sliding right inguinal hernia containing the capsule of the right kidney with acute obstruction (incarceration) of the right ureter. Painful palpation of the right kidney along with elevated inflammatory markers strongly indicated acute obstructive pyelonephritis, although urinalysis showed completely negative results. Due to the risk of ischemic damage to the right kidney and the ureter, as well as risk of urosepsis, we initiated empiric antibiotic therapy with ceftizoxime and recommended urgent surgery.\u003c/p\u003e\n\u003cp\u003eSurgery was performed under general anesthesia. A foley urinary catheter was inserted, and the urinary bladder was filled with 50ml normal saline. Through a standard inguinal incision, the external ring was visualized, and the hernia content was extracted from the right hemiscrotum revealing well bordered fatty tissue with a fibrous capsule. After the incision of the anterior wall of the inguinal channel, we identified an epigastric artery located medial to the hernia neck, confirming an anatomically indirect hernia. The spermatic cord was identified dorso-medially to the neck and isolated. Throughout the preparation of the hernia content, no peritoneal structures were involved. The ureter was located in the medial proximal part of the hernia and was pulled to the external orifice with significant dilatation of the proximal half. There were no signs of ischemia, and shortly after liberation, typical ureteral peristalsis was present. After the incision of the frontal wall of the fibroadipose tissue in the external inguinal ring, the inferior pole of the right kidney was revealed as part of the content of the hernia neck heading towards the hernia. Despite this, there were no signs of mechanical damage to the visible part of the kidney. After the complete separation of the ureter and manual repositioning of the kidney cranially, no other anatomical structures were found in the hernia neck. Almost the whole perirenal fat capsule, which was contained in the hernia, was completely resected at the level of inferior renal pole. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) The whole formation measured 23x10x6cm and weighed 850g.\u003c/p\u003e\n\u003cp\u003eThe right ureter was approximately 30cm long, and, as the kidney was dislocated in the right iliac fossa, the direct distance from the inferior pole to the urinary bladder was reduced to approximately 5cm. The ureter was, therefore, extremely crooked and prone to future kinking. As a result, we resected a 10 cm segment, ligated the distal part, and implanted the proximal segment to the bladder wall with a JJ stent. A sample for microbiology was taken from the ureter. A Redon drain was placed in the space of Retzi to control possible urinary leak. Finally, we performed a Liechtenstein hernioplasty using polypropylene mesh 10x15cm for definitive treatment of the inguinal hernia.\u003c/p\u003e\n\u003cp\u003ePerioperative microbiology showed sterile findings from the ureteral sample. The postoperative period was uneventful consisting of slight hematuria and satisfactory reduction of inflammatory parameters. Renal parameters showed no significant pathology. The urinary catheter was removed after 4 days, and the patient was discharged for outpatient treatment. The JJ stent was removed 6 weeks after the procedure.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe clinical symptoms of our patient were typical for acute appendicitis with no complaints of hernia changes or dysuria. Physical examination showed no specific findings of incarceration, and the kidney was not palpable due to central obesity. Many experienced surgeons rely on clinical findings to diagnose acute appendicitis, subsequently referring these patients for appendectomy. Although we do not consider ultrasonography a necessary measure, we request it in all clinically unclear cases, as well as in elderly patients. Our case suggests that ultrasonography should be considered a routine method if it is available.\u003c/p\u003e \u003cp\u003eThe CT scan showed obstruction of the right ureter and acute hydronephrosis. Acute obstructive pyelonephritis was very likely,considering significant elevation of inflammatory markers. We considered less invasive options, such as ureteral perturbation and percutaneous nephrostomy. Ureteral perturbation was likely to fail due to kinking of the ureter. While nephrostomy was easily achievable, only surgery was capable of providing definitive treatment.\u003c/p\u003e \u003cp\u003eThe normal anatomical position of the kidney is stabilized by the perirenal fat and fascias. The sliding of this fat capsule towards the inguinal channel and further to the inguinal hernia caused instability of the kidney position and its descent into the right iliac fossa and further towards the inguinal channel. The lack of any specific symptoms, apart from the apparent inguinal hernia, suggests that the process of descent was gradual.\u003c/p\u003e \u003cp\u003eThe right kidney was thoroughly examined with no signs of ischemia or other pathology. Resection of perirenal fat, shortening of the ureter, and hernia repair appear to be sufficient measures to stabilize the position of the kidney and maintain its full function.\u003c/p\u003e \u003cp\u003eLiberating the ureter from the hernia may be sufficient for the treatment of urinary obstruction; however, significant descent of the kidney increased risk of future ureteral kinking. At this point, resection of the ureter and neoimplantation was considered to be the best option.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAn inguinoscrotal hernia involving the perirenal fat capsule and ureter (ureteroinguinal hernia) is a rare condition with variable clinical presentations. It is associated with nephroptosis and may cause acute kidney obstruction and possible obstructive pyelonephritis. The clinical presentation in such a situation can persuasively mimic acute appendicitis. Ultrasonography and/or CT may not necessarily be performed in clinically clear cases of acute appendicitis; however, it is highly advisable to request further imaging when atypical local changes, e.g. inguinal hernia, are present.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT \u0026ndash; computer tomography\u003c/p\u003e\n\u003cp\u003eUS \u0026ndash; ultrasound\u003c/p\u003e\n\u003cp\u003eBMI \u0026ndash; body mass index\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: none\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e: all original data are included in patient\u0026acute;s medical records and internal medical database of University Hospital Bratislava. All data generated or analysed during this study are included in this published article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e has been obtained in Slovak language and are included in patient\u0026acute;s file\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Patient gave written informed consent for their personal or clinical details along with any identifying images to be published in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: Michal Gergel : managed the patient and conducted described surgery, wrote the manuscript; Ivan Brychta: supervised patient management and assisted with writing of the manuscript; Anita Lancz-Klikacova: prepared figures, assisted with literature research, did the outpatient follow-up; Alexander Mayer: supervised manuscript finalisation and literature research\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: none\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e: none\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTurner A, Subramanian P. \u0026ldquo;Ureteroinguinal Hernia: A Rare General Surgery Phenomenon.:\u0026rdquo;\u003cu\u003eCureus\u003c/u\u003e (2021): e20586. DOI: 10.7759/cureus.20586\u003c/li\u003e\n\u003cli\u003eAhmed S, Stanford R. \u0026ldquo;Ureteric obstruction secondary to a paraperitoneal inguinal hernia.\u0026rdquo;\u003cu\u003eAnn R CollSurg Engl.\u003c/u\u003e (2016): e16-e18. doi: 10.1308/rcsann.2016.0024.\u003c/li\u003e\n\u003cli\u003eBeebe K, Muhonen J, Giuseppucci P, Esper C. \u0026ldquo;A Rare Case of an Inguinal Hernia-Containing (Extraperitoneal) Ureter.\u0026rdquo;\u003cu\u003eAm J Case Rep.\u003c/u\u003e 2021; e930911-1\u0026ndash;e930911-5; doi: 10.12659/AJCR.930911\u003c/li\u003e\n\u003cli\u003eOsmani HT, Boulton R, Wyatt H, Saunders SM. \u0026ldquo;An unusual inguinoscrotal hernia with renal involvement.\u0026rdquo;\u003cu\u003eBMJ Case Rep.\u003c/u\u003e (2015): bcr2015211519; DOI: 10.1136/bcr-2015-211519\u003c/li\u003e\n\u003cli\u003eShchukin D, Demchenko V, Arkatov A, Stetsyshyn R, Khareba G, Bielov V. \u0026ldquo;\u0026quot;Extreme Nephroptosis\u0026quot;: A Kidney in the Inguinal Hernia.\u0026rdquo;\u003cu\u003e Case Rep Med.\u003c/u\u003e (2023); DOI: 10.1155/2023/1439919\u003c/li\u003e\n\u003cli\u003eKim J, Harper B, Turner A, Gonzalez IA, Andrade A. \u0026ldquo;Incarcerated native orthotopic kidney through an inguinal hernia: A case report and literature review.\u0026rdquo;\u003cu\u003eJ Surg Case Rep.\u003c/u\u003e (2023): rjad378; doi: 10.1093/jscr/rjad37\u003c/li\u003e\n\u003cli\u003eLossius MN, Araya CE, Henry DD, Neiberger RE. \u0026ldquo;A patient with an unusual cause right lower quadrant pain and vomiting: pyelonephritis of an ectopic right kidney masquerading as acute appendicitis.\u0026rdquo;\u003cu\u003eCase Rep Med.\u003c/u\u003e (2009): 638501; doi: 10.1155/\u003cstrong\u003e2009\u003c/strong\u003e/638501\u003c/li\u003e\n\u003cli\u003eManglik A, Tomar L, Akash A. \u0026ldquo;Pyelonephritis of an ectopic right kidney pretending as acute appendicitis: An unusual case.\u0026rdquo;\u003cu\u003eInt J Surg Case Rep\u003c/u\u003e (2022): 107490. DOI: 10.1016/j.ijscr.2022.107490\u003c/li\u003e\n\u003cli\u003eXu YE, Hendahewa R. \u0026ldquo;A rare presentation of an ectopic kidney with pyelonephritis mimicking appendicitis.\u0026rdquo;\u003cu\u003eJ Surg Case Rep.\u003c/u\u003e (2019): rjz342; DOI: 10.1093/jscr/rjz342\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ureteroinguinal hernia, acute appendicitis, ureteral incarceration","lastPublishedDoi":"10.21203/rs.3.rs-4417905/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4417905/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe involvement of kidney, perirenal fat, and ureter is a rare variant of inguinal hernia. We report a case of a 78-year-old man presenting with typical clinical signs of acute appendicitis. Ultrasonography and CT scan revealed ptosis of the right kidney with a major part of the perirenal capsule involved in a large right sided inguinal hernia with acute obstruction of the ureter and urostasis. Acute surgery was performed, involving resection of perirenal fat, liberation, resection, and neoimplantation of the ureter, and hernioplasty. The postoperative period was uneventful. This case illustrates diagnostic unpredictability of acute appendicitis as well as anatomic variety of inguinal hernias.\u003c/p\u003e","manuscriptTitle":"Nephroptosis and ureteroinguinal incarcerated hernia mimicking acute appendicitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-02 17:27:46","doi":"10.21203/rs.3.rs-4417905/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-21T08:37:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-20T14:41:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80893660350997539517129855275644960076","date":"2024-06-20T08:12:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-19T18:28:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-19T12:38:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"90207722591094951111520672904361781192","date":"2024-06-18T15:36:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-17T21:49:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174508157549940835048242476653421144846","date":"2024-06-17T21:00:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31808272340511037847835742204955877527","date":"2024-06-17T12:20:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110194964217085761470281402797367975808","date":"2024-06-16T19:19:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100925814153516859495637493612701424996","date":"2024-06-16T19:09:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-15T16:15:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49296693972218148056436294224371796965","date":"2024-06-15T16:05:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-13T15:15:57+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-10T14:19:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-10T14:17:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-10T14:17:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-05-14T09:02:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a9bb25d1-03d9-4308-a3be-560a9aeea470","owner":[],"postedDate":"July 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-05T16:08:12+00:00","versionOfRecord":{"articleIdentity":"rs-4417905","link":"https://doi.org/10.1186/s12894-024-01549-x","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2024-07-29 15:57:10","publishedOnDateReadable":"July 29th, 2024"},"versionCreatedAt":"2024-07-02 17:27:46","video":"","vorDoi":"10.1186/s12894-024-01549-x","vorDoiUrl":"https://doi.org/10.1186/s12894-024-01549-x","workflowStages":[]},"version":"v1","identity":"rs-4417905","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4417905","identity":"rs-4417905","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}