Recurrent Left Ureterosciatic Herniation With Obstructive Hydronephrosis: A Case Report

Uretero-sciatic herniation is an exceptionally rare cause of ureteric obstruction, resulting from herniation of the ureter via the sciatic foramen. A 66-year-old woman presented with left flank pain and deteriorating renal function. Computed tomography intravenous pyelogram (CT IVP) demonstrated severe left hydronephrosis secondary to herniation of the ureter through the left sciatic foramen. The patient then underwent successful renal decompression with an endoscopic retrograde ureteric stent placed. Subsequent trial of stent removal failed, with left uretero-sciatic herniation and renal obstruction recurring shortly after stent removal. Multidisciplinary review led to further evaluation for potential underlying pathology and subsequent definitive open ureterolysis, ureteric reduction and omental wrapping being performed. This case report highlights the pertinent clinical, radiological and management principles underlying such rare pathology. The possible association of piriformal atrophy as an underlying precipitant is discussed along with the key radiological findings of such rare pathology. Within the literature, evidence-based definitive management options are limited and currently require multidisciplinary discussion with invasive surgical correction to be considered following failure of more minimally invasive endoscopic management. In this case, given the success of open ureterolysis and omental wrapping, it is hoped future cases may benefit from this knowledge and consider similar surgical approaches to achieve definitive management.