title: A rare diaphragmatic ureteral herniation case report: endoscopic and open reconstructive management.
abstract: BACKGROUND
  Ureteral herniations are a rare occurrence, generally found incidentally on cross sectional imaging or during surgical intervention for unrelated processes. Several locations of ureteral herniations can occur including the inguinal, femoral, sciatic, obturator, and thoracic regions. While few reports of ureteral hernias are reported in the literature overall, the vast majority of those reported are inguinoscrotal herniations found during evaluation and treatment of inguinal hernias. Pelvic outlet ureteral herniations intrinsically are more common secondary to their dependent locations. Intrathoracic ureteral herniations through diaphragmatic defects are an exceptionally rare subset of ureteral herniations and have only been described sparingly. Fewer than ten case reports of diaphramatic ureteral herniations have been reported and none have described both cystoscopic management and open reconstruction.
  
  
  METHODS
  We report the case of a 81 year old female with flank pain who was found to have idiopathic diaphragmatic hernia with incarcerated proximal ureter. She had no prior injury or surgery that explained her clinical presentation. She was initially observed and then managed conservatively with ureteral stent exchanges. Ultimately she underwent open surgical repair of her diaphragmatic hernia, reduction, resection and anastomosis of redundant proximal incarcerated ureteral segment, and nephropexy for a hypermobile right renal unit. This case report illustrates the pre- and post-operative imaging studies of a very rare intrathoracic ureteral herniation as well as surgical approach to repair.
  
  
  CONCLUSIONS
  A herniated ureter is a potential source of serious renal and ureteral complications. The thoracic herniation of ureter is the rarest of the ureteral herniations. When discovered, they should be managed to preserve renal function and prevent strangulation of the affected segment of ureter. This case report documents the treatment of a thoracic ureteral herniation with observation, conservative endoscopic management, and finally open surgical reconstruction.
authors.affiliation: Division of Urology, Department of Surgery, University of Arizona, 1501 N. Campbell Ave, Tucson, AZ, 85724, USA. flin@email.arizona.edu.
authors.forename: Frank C
authors.initials: FC
authors.lastname: Lin
authors.affiliation: Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Civic Blvd, Philadelphia, PA, 19104, USA.
authors.forename: Jamie S
authors.initials: JS
authors.lastname: Lin
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave, Tucson, AZ, 85724, USA.
authors.forename: Samuel
authors.initials: S
authors.lastname: Kim
authors.affiliation: Division of Urology, Department of Surgery, University of Arizona, 1501 N. Campbell Ave, Tucson, AZ, 85724, USA.
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Walker
mesh_terms: D000369:Aged, 80 and over; D004724:Endoscopy; D005260:Female; D006548:Hernia, Diaphragmatic / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D014057:Tomography, X-Ray Computed; D014513:Ureter / Q000000981:diagnostic imaging / Q000601:surgery*; D014515:Ureteral Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D014517:Ureteral Obstruction / Q000000981:diagnostic imaging / Q000209:etiology
keywords: Case report; Diaphramatic hernia; Renal obstruction; Ureter; Ureteral hernia; Ureteral reconstruction