Internal hernia from the interureteric space after robot-assisted radical cystectomy and urinary diversion: Two case reports

RATIONALE: Radical cystectomy and urinary diversion remains the definite management for muscle invasive bladder urothelial cancer. Internal herniation caused by ureteral adhesion is an extremely rare complication after the procedure. To the best of our knowledge, this is the first case report of small bowel obstruction and internal herniation occurring between bilateral ureters and urinary diversion after robot-assisted radical cystectomy (RARC). PATIENT CONCERNS: A 64-year-old woman presented with symptom of small bowel obstruction such as nausea, vomiting, and abdominal fullness after RARC and Indiana pouch. Another 61-year-old man presented with left obstructive hydronephrosis and recurrent pyelonephritis after RARC and ileal conduit. DIAGNOSIS: Both patients received computed tomography scans and the results were suggestive of small bowel herniation between bilateral ureters and urinary diversion. INTERVENTIONS: The 2 patients underwent open ureterolysis and internal hernia reduction. During the operation, bowel loop herniation between the interureteral spaces were found. OUTCOMES: Both patients recovered smoothly after second operation. LESSONS: The incidence of internal herniation may increase by the growing use of RARC. Suitable stoma position, appropriate length of ureter dissection, and retroperitonealization can help prevent this complication.