Tag Archive for: ureteric obstruction


Right sided Bochdalek hernia causing ureteric obstruction

We report a case in a elderly female who presented with symptomatic BH causing obstruction of the right renal pelvis and ureter.


Authors: Vikram Balakrishnan, MBBS, BMedSc, Dip. Surg Anatomy; Gregory Neerhut MBBS, FRACS.

Urology Unit, Geelong Hospital, Victoria, Australia

Corresponding Author: Vikram Balakrishnan, Urology Unit, Geelong Hospital, Victoria, Australia.  T: +613 421 709 541  Email: [email protected]


Bochdalek hernia (BH) is a congenital hernia of the diaphragm that occurs in 1 in every 2200 to 12,500 births with an overall prevalence in adults of between 0.17% and 10.5% [1-4]. It results from developmental failure of the posterolateral diaphragmatic foramina to fuse properly and most commonly presents during the neonatal period [5]. Adult patients presenting with symptomatic BH, especially on the right side, are exceedingly rare, and there have been less than 20 cases reported in the literature [6,7]. We report a case in a elderly female who presented with symptomatic BH causing obstruction of the right renal pelvis and ureter.


Case Report
An 83 year old female presented to the emergency department with severe right flank pain on a background of a 12 month history of intermittent mild flank pain. Her past history included chronic renal impairment and right renal colic. Clinical examination revealed a frail elderly lady with normal vital signs. There was some mild flank tenderness on the right and respiratory examination was normal. Creatinine was chronically elevated at 192umol/L, eGFR was 23mL/min, white cell count was 12.0 10^9g/L (reference rage 4-11.0 x10^9 g/L) and the urine was sterile. Plain radiographs of the abdomen demonstrated degenerative changes of the lumbar spine consistent with osteoarthritis and there was no evidence of kidney stones. The patient was discharged with a presumptive diagnosis of chronic back pain.
At outpatient follow-up, the patient had ongoing flank pain and ultrasound demonstrated normally sized and positioned kidneys with hydronephrosis of the right collecting system and a renal pelvis measuring 6cm in diameter. A computerised tomography (CT) scan demonstrated a small BH of the posterior aspect of the right diaphragm. The dilated renal pelvis was drawn superiorly through the hernia into the thorax with the pelviureteric junction located superior to the remainder of the collecting system. The ureter then passed inferiorly through the neck of the Bochdalek hernia back into the abdomen. There was no dilatation of the ureter below the hernia (Figure 1 and 2).

Figure 1. Axial CT scan demonstrates dilated right renal pelvis drawn superiorly through the diaphragmatic hernia



Figure 2. Coronal CT scan demonstrates distended ureter and renal pelvis above the neck of the Bochdalek hernia and normal calibre ureter below



Rigid cystoscopy and a right retrograde pyelogram demonstrated superior and medial deviation of the proximal ureter with kinking of the ureter and proximal hydronephrosis (Figure 3).

Figure 3. Retrograde pyelogram pre and post double J stent placement



A guide-wire was passed to the renal pelvis without difficulty and a 6 French double J stent was placed. The patient’s pain resolved immediately, she made an uneventful recovery and was discharged home the following day. The stent is changed electively every six months and 12 months following presentation she remains pain free.


Congenital diaphragmatic hernia was first described by Vincent Alexander Bochdalek in 1848 and results from incomplete closure between the pars lumbaris and pars costalis parts of the diaphragm during fetal development [5,8]. The majority of patients present during neonatal life with concomitant congenital pulmonary abnormalities and consequently have a poor prognosis [1]. Adult presentation with symptomatic BH is rare with approximately 100 cases reported in the literature. Whilst asymptomatic BH tend to occur equally on the right and left hand sides of the diaphragm [3,4], symptomatic BH tend to occur on the left with a ratio of 9:1 [1,2]. The contents of BH depend on the side of the hernia and have included liver, omentum, bowel, spleen, kidneys and stomach [1,10]. The presence of renal pelvis or ureter within a BH is exceedingly rare with only three cases reported in the literature [11-13].
The clinical presentation of BH in adults ranges from an incidental finding on imaging to strangulation of intra-abdominal contents with significant morbidity and mortality. Symptoms are often non-specific and include abdominal pain, dyspnea, chest pain and nausea and vomiting [10]. Of the three cases reported in the literature on BH containing ureter, one was asymptomatic and was discovered incidentally [11], one presented with right upper quadrant pain [12] and the other presented almost identically to our case with a 12 month history of intermittent flank pain [13]. Precipitating factors are sometimes identified and include any mechanism that increases intra-abdominal pressure, however, the patient in our study did not have any history of chronic cough or constipation.
Diagnosis is ultimately via imaging and CT provides the most accurate and reliable method [2,14]. Discontinuity of the posterior diaphragm is usually clearly identified and protrusion of intra-abdominal contents including ureter is clear [2,5,14]. Importantly, CT can identify associated complications of ureteric herniation including hydronephrosis and hydroureter, which is evidenced by dilatation above the hernia neck and a normal calibre ureter below. Of the three reported cases on BH containing ureter, two were associated with obstructive uropathy with similar CT findings to our case [12,13]. Ultrasound, whilst able to identify hydronephrosis in our case, was not able to identify the hernia or the site of obstruction.
The optimal treatment of BH causing obstructive uropathy is unclear. Despite kinking of the ureter we were able to successfully pass a double J stent to the renal pelvis which provided immediate relief of the patient’s symptoms. Similarly, Song et al [14] were able to successfully pass a retrograde stent with follow-up CT confirming resolution of hydronephrosis. Definitive surgical correction of BH is recommended because of the risk of herniation and strangulation of abdominal viscera and excellent outcomes have been described with no evidence of hernia recurrence [10]. In particular, laparoscopic repair with or without mesh appears to be reliable and confers all the benefits of minimally invasive surgery [15]. However, diaphragmatic surgery is not without complications and elderly patients in particular gain only a minimal benefit as the risk of further herniation over their remaining lifetime is low.
Our elderly frail patient was managed with a retrograde ureteric stent. Patients managed this way need to have their stent changed every 6 to 12 months because of the risk of stent encrustation causing obstruction. In addition, these patients should have regular imaging such as chest radiography because, as discussed, clinical symptoms and signs may not correlate with severity of disease. In a younger fitter patient we would recommend surgical correction of the hernia.


We described the case of an 83 year old female presenting with a right sided BH containing the right renal pelvis and ureter causing pain, hydronephrosis and hydroureter. Symptomatic BH in adult patients is rare and there have been only three cases of BH containing ureter in the literature. Ureteric stent offers a safer alternative to surgical repair of the hernia and may be a more appropriate treatment in elderly patients.


1. Gedik E, Tuncer MC, Onat S, Avci A, Tacyildiz I, Bac B. A review of Morgagni and Bochdalek hernias in adults. Folia Morphol (Warsz). 2011 Feb;70(1):5-12.
2. Wilbur AC, Gorodetsky A, Hibbeln JF. Imaging findings of adult Bochdalek hernias. Clin Imaging. 1994 Jul-Sep;18(3):224-9.
3. Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR Am J Roentgenol. 2001 Aug;177(2):363-6.
4. Temizöz O, Gençhellaç H, Yekeler E, Umit H, Unlü E, Ozdemir H, Demir MK. Prevalence and MDCT characteristics of asymptomatic Bochdalek hernia in adult population. Diagn Interv Radiol. 2010 Mar;16(1):52-5. Epub 2009 Dec 28.
5. Sandstrom CK, Stern EJ. Diaphragmatic hernias: a spectrum of radiographic appearances. Curr Probl Diagn Radiol. 2011 May-Jun;40(3):95-115.
6. Rout S, Foo FJ, Hayden JD, Guthrie A, Smith AM. Right-sided Bochdalek hernia obstructing in an adult: case report and review of the literature. Hernia. 2007 Aug;11(4):359-62. Epub 2007 Mar 7.
7. Agrafiotis AC, Kotzampassakis N, Boudaka W. Complicated right-sided Bochdalek hernia in an adult. Acta Chir Belg. 2011 May-Jun;111(3):171-3.
8. Haller JA Jr. Professor Bochdalek and his hernia: then and now. Prog Pediatr Surg. 1986;20:252-5.
9. Bujanda L, Larrucea I, Ramos F, Muñoz C, Sánchez A, Fernández I. Bochdalek’s hernia in adults. J Clin Gastroenterol. 2001 Feb;32(2):155-7.
10. Brown SR, Horton JD, Trivette E, Hofmann LJ, Johnson JM. Bochdalek hernia in the adult: demographics, presentation, and surgical management. Hernia. 2011 Feb;15(1):23-30. Epub 2010 Jul 8.
11. Chawla K, Mond DJ. Progressive Bochdalek hernia with unusual ureteral herniation. Comput Med Imaging Graph. 1994 Jan-Feb;18(1):53-8.
12. Song YS, Hassani C, Nardi PM. Bochdalek hernia with obstructive uropathy. Urology. 2011 Jun;77(6):1338. Epub 2010 Jul 1.
13. Paterson IS, Lupton EW. Pelviureteric junction obstruction secondary to renal pelvic incarceration in a congenital diaphragmatic hernia. Br J Urol. 1989 Nov;64(5):548-9.
14. Shin MS, Mulligan SA, Baxley WA, Ho KJ. Bochdalek hernia of diaphragm in the adult. Diagnosis by computed tomography. Chest. 1987 Dec;92(6):1098-101.
15. Palanivelu C, Rangarajan M, Rajapandian S, Amar V, Parthasarathi R. Laparoscopic repair of adult diaphragmatic hernias and eventration with primary sutured closure and prosthetic reinforcement: a retrospective study. Surg Endosc. 2009 May;23(5):978-85. Epub 2009 Mar 14.


Date added to bjui.org: 03/12/2011

DOI: 10.1002/BJUIw-2011-104-web


Calcified ureterocoele causing renal tract obstruction in an adult

We believe this is the first report of a calcified ureterocoele, containing no calculi, and causing significant renal tract obstruction in an adult.


Corresponding Author: Ashley Ridout, Croydon University Hospital, Department of Urology, Croydon, UK. Email: [email protected]

The ureterocele is an intravesical cystic dilatation of the terminal ureter, often due to a congenital weakness in the lower ureteric wall.  Adult orthotopic ureterocoeles, although more common in women, remain a rare clinical entity. We believe this is the first report of a calcified ureterocoele, containing no calculi, and causing significant renal tract obstruction in an adult. We report the case of an elderly Caucasian female patient, presenting with a calcified, right sided, simple orthotopic ureterocoele, mimicking a right vesicoureteric junction (VUJ) calculus.


Case Report
An 84-year old female presented to the emergency department with a short history of worsening right-sided abdominal pain. Cognitive function was well preserved despite significant medical comorbidities, including a previous cerebrovascular accident with residual right hemiplegia, atrial fibrillation (for which she was taking warfarin), giant cell arteritis, ischaemic heart disease and congestive cardiac failure. On general examination, the patient appeared cushingoid and was drowsy, confused, tachycardic and hypotensive. Abdominal examination revealed tenderness in the right loin and right iliac fossa, with no evidence of peritonism. Blood tests revealed acute renal failure (Ur 14.2, Cr 145), raised inflammatory markers (CRP >250) and a raised serum lactate (6.7). The patient was also in fast atrial fibrillation, with rate-related ischaemia evident on ECG.
The patient responded well to appropriate fluid resuscitation and intravenous antibiotics. Ultrasound of the renal tract reported right hydronephrosis, with a calculus at the right vesicoureteric junction. Subsequent CT scan of the abdomen & pelvis reported a calculus at the right VUJ and moderate right hydronephrosis and hydroureter (Figure 1a/1b).


Figure 1a. CT scan 


Figure 1b. CT scan 


Although no calculus was identifiable on limited IVU, hydronephrosis and hydroureter in a single collecting system with obstruction at the level of the right VUJ was reported. The ‘cobra head’ sign pathognomic of a ureterocele was not evident.
Once clinically stable and fit for general anaesthetic, retrograde ureteric stenting was arranged. During the procedure, a ureterocoele was noted at the right ureteric orifice. The site and appearance of the left ureteric orifice was cystoscopically normal. Transurethral de-roofing of the right ureterocoele was performed. No calculus was present in the ureterocele, or at the vesicoureteric junction. A ureteric stent was inserted without complication, and the patient recovered well from the procedure. Renal function normalised (Creatinine 79, Urea 7) and the patient was discharged three days after the procedure. The stent was removed without incident 4 weeks post-procedure, and the patient remains well.


The ureterocoele is a congenital abnormality, commonly now identified with antenatal screening. Ureterocoeles may be either intravesical or ectopic in location, and there is a great clinical spectrum of symptoms and functional consequences. The precise aetiology of ureteroceles is uncertain – it is most widely accepted that obstruction of the ureteral orifice during embryogenesis, with incomplete dissolution of the Chwalla membrane, predisposes to ureterocoele formation. Occasionally, ureterocoeles are discovered in adulthood – these are typically intravesical, and associated with a single collecting system[1]. Presentation may include flank/back pain, recurrent urinary tract infections, urosepsis, voiding difficulty or loin to groin pain. In addition, they may be detected incidentally at endoscopy, or radiologically[1-5].  Stones are known to form in ureterocoeles, thought to be secondary to ureteral atony and urinary stasis – it is reported that stone formation in ureterocoeles in more common in males than females [1,5].
In our patient, the decision for retrograde stenting instead of nephrostomy and antegrade stenting was based on availability of resources at the time for urgent intervention.  If antegrade stenting were performed, the ureterocoele may not have been identified and treated, as was the outcome in our patient. Endoscopic management is the gold standard therapy for management for symptomatic adult ureterocoele [2,6].  Timely diagnosis and endoscopic de-roofing of obstructing ureterocoeles may avert recurrent presentations with infection and obstruction, and thereby significantly reduce subsequent morbidity. This is especially important in patients such as ours, with multiple other co-morbidities, which may be exacerbated by episodes of sepsis.
Adult ureterocoele, although an uncommon clinical entity, should be considered in the differential diagnoses of patients presenting with urinary symptoms. Cystoscopic examination in those presenting with refractory and/or severe urinary symptoms may allow correct and timely recognition and management of previously unidentified ureterocoeles.


We believe this is the first reported case of a ureterocoele mimicking a ureteric calculs. Our patient was admitted acutely unwell, with urinary sepsis and radiological findings suggestive of obstructing ureteric stone. The cystoscopic finding of a calcified ureterocoele, with no obstructing calculus, was unexpected. After definitive management of the ureterocoele, the patient recovered rapidly, and remains well.




1. Vasu TS, Elliot WC, Lai RS. Bilateral ureteroceles progressing to reversible acute renal failure in an adult.
Can J Urol. 2006 Feb;13(1):2993-6
2. Halachmi S, Pillar G. Congenital urological anomalies diagnosed in adulthood – management considerations.
J Pediatr Urol. 2008 Feb;4(1):2-7
3. Tomaszewski JJ, Turner RM 2nd, Ost MC. Stone Cobras: Adult bilateral single system ureteroceles presenting with multiple calculi.
Urology 2011 Feb 17 (Epub ahead of print)
4. Berger MB, Larson KA, DeLancey JO. An incidental finding: routing cystoscopy after pelvic floor reconstruction surgery revealed a bladder mass.
Am J Obstet Gynecol. 2010 Nov;203(5):518e1
5. Shamsa A, Asadpour AA, Abolbashari M, Hariri MK. Bilateral simple orthotopic ureteroceles with bilateral stones in an adult: a case report and review of literature.
Urol J. 2010 Summer;7(3):209-11
6. Singh I. Adult bilateral non-obstructing orthotopic ureteroceles with multiple calculi: endoscopic management with a review of literature.
Int Urol Nephrol. 2007;39(1):71-4


Date added to bjui.org: 17/10/2011 

DOI: 10.1002/BJUIw-2011-076-web


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