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Year : 2010  |  Volume : 26  |  Issue : 1  |  Page : 131-132

Thoracic curlicue: A case of ureteral herniation

Department of Urology, Amrita Institute of Medical Sciences and Research Centre, Kochi, India

Date of Web Publication23-Mar-2010

Correspondence Address:
Sudhir Sukumar
Department of Urology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala - 682 041
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-1591.60462

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Isolated herniation of ureter into thoracic cavity due to a defect in the diaphragm is a very rare entity. We present clinical details and radiographic images of an incidentally detected herniation of right ureter into the thorax in an elderly lady with no previous history of trauma or urinary tract symptoms. This acquired but asymptomatic condition is confirmed by radiologic imaging that reveals the classical loop configuration which is described as the curlicue sign. Further evaluation had revealed mild renal failure but with no definite evidence of obstruction. In view of age and asymptomatic status, patient was offered non-surgical management.

Keywords: Ureter, diaphragm, hernia

How to cite this article:
Sukumar S, Kumar P G, Thomas A. Thoracic curlicue: A case of ureteral herniation. Indian J Urol 2010;26:131-2

How to cite this URL:
Sukumar S, Kumar P G, Thomas A. Thoracic curlicue: A case of ureteral herniation. Indian J Urol [serial online] 2010 [cited 2021 Jul 27];26:131-2. Available from:

   Introduction Top

Ureteral herniation is a rare entity of which fewer than 200 cases have been reported, being usually detected incidentally during radiological evaluation or during surgery. [1] They have been described in inguinal, femoral, sciatic, and parailiac locations; [1] occurrence in the thoracic cavity is considered extremely rare.

   Case Report Top

A 75 year-old lady with long-standing hypertension was detected to have mild renal failure during evaluation for an upper respiratory infection. She did not give any history of colics, previous episodes of urinary tract infections, or trauma to the chest or abdomen. A subsequent abdominal ultrasonogram revealed mild right hydroureteronephrosis with slightly decreased parenchymal thickness.

In view of her altered renal functions, a noncontrast computed tomography scan was done which revealed a relatively small right kidney that was displaced cranially towards the diaphragm; the renal axis was abnormal with the pelvis facing posterosuperiorly [Figure 1]a. Along with retroperitoneal fat, the dilated right ureter could be seen herniating into the ipsilateral thoracic cavity through a 2.6 cm wide defect in the posteromedial aspect of the right hemidiaphragm [Figure 1]b, which was suggestive of a Bochdalek hernia. The lower chest sections showed the ascending and descending limbs of the herniated ureter in a loop configuration [Figure 1]b. The descending ureter appeared to be compressed at the location of the diaphragmatic defect. A subsequent retrograde pyelogram confirmed the classical ureteral loop or knuckle, which has been described as the curlicue sign [Figure 2]. It also demonstrated prompt and complete emptying of the pelvicalyceal system, thus ruling out an obstructive cause for the renal failure. Hence, it was decided to manage the patient's renal failure with medical measures. Future surgical intervention has been planned only if there are chest symptoms due to the mass effect, or if renal failure can be definitely attributed to the anatomical anomaly.

   Discussion Top

Isolated ureteral herniation through a diaphragmatic defect has been sparingly reported in literature; [2,3] these previous reports have also been incidentally detected during either surgery or radiological imaging. Although rare, these are believed to be acquired and the incidence increases with age, being common in those with emphysematous chests. [4] A preponderance has been observed for the female sex [4] and the right side. [1]

Our patient did not give any history favoring a traumatic etiology for the diaphragmatic defect, and hence, may also be assumed to have acquired it due to age-related degeneration. The defect is thought to occur at the junction between the crus and the posterior diaphragmatic fibres. [4]

The diagnosis of ureteral hernia at any site can be confirmed on radiological imaging by the curlicue sign that occurs due to a ureteral loop or spiral. [5] This classical appearance can be demonstrated in erect and oblique projections of roentgenographic images during the excretory phase. [1],[5] They are also evident in coronal and axial computed tomographic imaging. [2],[3],[4],[5] The herniation may be gradually progressive, involving long segments of the ureter, but may not always require surgical intervention. [2] However, persistence can lead to ureteral obstruction, colics, and subsequent compromise of renal function, besides chest discomfort and respiratory distress in large defects.

   Conclusion Top

Ureteral hernias into the thoracic cavity are extremely rare but are easily diagnosed by the sign of the curlicue ureter. They are usually asymptomatic but early diagnosis may be beneficial, especially in a setting of renal failure.

   References Top

1.Curry NS. Hernias of the urinary tract. In: Pollack HM, McClennan BL, editors. Clinical Urography. 2 nd ed. Philadelphia: WB Saunders Company; 2000. p. 2987-9.  Back to cited text no. 1      
2.Chawla K, Mond DJ. Progressive Bochdalek hernia with unusual ureteral herniation. Comput Med Imaging Graph 1994;18:53-8.  Back to cited text no. 2  [PUBMED]    
3.Catalano O, Nunziata A, Cusati B, Siani A. Retrocrural loop of the ureter: CT findings. AJR Am J Roentgenol 1998;170:1293-4.  Back to cited text no. 3  [PUBMED]    
4.Caskey CI, Zerhouni EA, Fishman EK, Rahmouni AD. Aging of the diaphragm: A CT study. Radiology 1989;171:385-9.  Back to cited text no. 4  [PUBMED]    
5.Crespi-Porro R, Conti A, Campagnari S. Radiodiagnosis of ureteral and bladder hernia: A further case contribution. Radiol Med 1992; 84:424-30.  Back to cited text no. 5  [PUBMED]    


  [Figure 1], [Figure 2]

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[Pubmed] | [DOI]


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