Ureterosciatic hernias occur when the ureter herniates between muscles of the pelvic floor, namely superior to the piriformis through the greater sciatic foramen, and inferior to the gluteus minimus.1 The incidence of such hernias is quite low; only a few other case reports exist, and there are no official incidental data.
Interestingly, all the case report subjects are female.2 It is believed that fewer than 40 other instances have occurred worldwide,2 with the first case documented in 1947 by Ake Lindbom, MD (hence this type of hernia is sometimes referenced as a Lindbom hernia).3
The etiology of these hernias is unknown but is likely a combination of pelvic floor muscle atrophy,4 adhesions, fascial loss, and congenital anatomic malformations of the ureter or pelvic floor.3,4 History of childbirth also is believed to increase risk. The most common path through which a ureter herniates is the inguinal canal into the scrotum. Bowel, bladder, or ovary also may herniate through the sciatic foramen.
While ureterosciatic hernias may be asymptomatic, they also can cause abdominal pain and urinary symptoms such as frequency, urgency, burning, or hematuria. This classification of hernias can cause urinary tract infections, pyelonephritis, and hydronephrosis upstream from the hernia, especially if it becomes incarcerated. Although these hernias have the ability to spontaneously reduce, they can become incarcerated or strangulated and must be diagnosed via imaging such as computed tomography (CT) scan or retrograde pyelogram, which will show the “curlicue sign” of a tortuous ureter with a U-shaped or omega-shaped ureter trapped in a defect.5
HPI/Hospital Course
The patient, a 59-year-old female, was seen urgently in the emergency room in 2024 for evaluation of nausea, flank pain, and difficulty urinating that began the night before presentation. She reported that she was pushing hard to urinate, then began to experience left-sided flank pain. Her pain and nausea worsened, which prompted her to present to the emergency department.
She was in her usual state of health beforehand. A CT scan of the abdomen and pelvis revealed left-sided hydronephrosis with forniceal rupture and urinoma, for which treatment is placement of a double-J stent.6 It also showed what appeared to be a ureterosciatic hernia on the left, with no signs of ureterolithiasis. She presented afebrile with a creatinine level of 1.0, white blood cell count of 16,000, and lactate level of 3.4, meeting sepsis criteria. Her urinalysis was negative for hematuria or infection. She received ceftriaxone and hydromorphone in the emergency department.
The patient consented to have a left ureteral stent placed in the OR later that morning. The stent was placed with some difficulty by Dr. Gerstein. She tolerated the procedure well without complications and reported that her flank pain resolved.
After overnight observation, her white blood cell count decreased to 13,000, her kidney function remained stable, and her lactate normalized. She was discharged from the hospital in good condition the next day, with follow-up set up with Karen A. Chojnacki, MD, FACS, to repair the hernia,6 which was repaired surgically later that year.
Description of Operation
The procedure conducted by Dr. Chojnacki was a robotic-assisted repair of ureterosciatic hernia with ureteral mobilization and intraperitonealization.
After supine positioning and induction of general endotracheal anesthesia, a urinary catheter was placed, followed by prepping and draping, incisions, and robotic docking.
The small bowel was mobilized out of the pelvis. The white line of Toldt of the colon was incised, and the left colon was mobilized from lateral to medial until the gonadal vessels and ureter were exposed. The ureter was carefully dissected out of the retroperitoneum and encircled with a vessel loop.
The ureterolysis was continued from the intersigmoidal fossa down to the ureterovesical junction. There was entrapment of the ureter within the sciatic hernia. The adhesions between the ureter were carefully lysed, and the ureter was removed from the sciatic hernia. Once ureteral mobilization was completed, the hernia was easily seen and measured approximately 1.5 cm in diameter. The peritoneal flap was created inferiorly and superiorly to accommodate a small piece of soft mesh.
To facilitate visualization, the left tube and ovary were tacked to the anterior abdominal wall using suture. A 4 x 4-cm piece of soft mesh was introduced into the peritoneal cavity. This was positioned in the pelvis to cover the sciatic hernia, and the peritoneum was then closed over this mesh with care taken to make sure the mesh remained flat and across the hernia defect. The peritoneum was closed with absorbable suture. The ureter was left on the peritoneal side of this closure. Therefore, it was ensured that the peritoneal closure was not too tight on either the proximal or distal ureter.
A urologist was present to confirm that leaving the ureter intraperitoneal was safe and that the ureter had been mobilized safely with no evidence of injury. The mesh had been peritonealized completely, and the ureter was left on the intraperitoneal side for a distance of approximately 7 cm.
Follow-Up Procedures and Visits
In December 2024, the patient followed up with Dr. Gerstein for a left-sided stent check and possible removal in the OR. (She had been experiencing some stent colic since placement a few months prior.)
Fluoroscopy revealed the stent was in good position with a straight contour throughout its course. Cystoscopy and ureteroscopy were performed. The ureteroscope was able to be advanced to the portion of ureter previously involved in the hernia, and visual inspection revealed this portion to be widely patent and without tortuosity or obstruction. Some nonspecific mucosal changes were noted in this area. The scope then focused on the ureteral orifice into the bladder; brisk efflux of clear urine was appreciated, as was ureteral peristalsis. The decision was made not to replace the stent.
In February 2025, the patient was seen by Dr. Gerstein during a follow-up visit. She reported feeling much better without the stent and a 6-month follow-up ultrasound was arranged from that date.
In July 2025, the ultrasound showed normal kidneys, no hydroureteronephrosis, and a normal-appearing bladder. She denied experiencing any abdominal or urinary symptoms, and it was determined that no scheduled follow-up was required. Because she was symptomatic at original presentation, she will be seen as needed and will re-engage if the symptoms return.
The patient has thus far been stable with no urologic complaints or return visits to the hospital since her scheduled follow-up visits.
Treatments for ureterosciatic hernias have included observation (usually reserved for asymptomatic cases), nephrostomy placement, ureteral stenting alone,3 and ureteral stenting with delayed surgical repair (with or without mesh).7 If incarcerated ureter is discovered to be unviable during surgical hernia repair, ureteral reconstruction should be performed and a ureteral anastomosis created.5 To this day, there are no fixed guidelines for treatment.2
Fewer than 10 other robotic-assisted repairs of this rare hernia had been documented,8,9 in addition to some nonrobotic laparoscopic repairs.10 Open and transgluteal surgical repairs are not recommended.5 The initial presentations and treatments vary, but successful long-term management of these patients can be achieved with surgical intervention or regular ureteral stent exchanges.
