Peritoneal dialysis (PD) is a therapeutic option for patients with end-stage kidney disease (ESKD) that offers better dynamism, independence, and quality of life than hemodialysis (HD) ¹. Patients usually initiate PD by manually performing dwells, a method known as continuous ambulatory peritoneal dialysis (CAPD). However, PD is associated with complications such as malfunctions of the dialysis catheter (DC), infections (peritonitis, infections of the peritoneal DC, and tunnel and exit site infections), and abdominal wall defects with inguinal hernia (IH) that may present rarely with acute scrotal edema ². Abdominal wall hernias and scrotal edema are potential complications of PD in adults that may force interruption of the therapy. In contrast to children, in whom inguinoscrotal hernia through a patent processus vaginalis (PPV) is common, such pathology is very rare in adults.

We herein report the case of a 72-year-old man with end-stage kidney disease (ESKD) and a history of type 2 diabetes, arterial hypertension, obesity (BMI>31 kg/m²), hypercholesterolemia, and a history of bilateral IH treated by open Stoppa tension-free mesh hernioplasty (TFMH). A Tenchkoff PD catheter had been placed simultaneously to hernia repair because of advanced chronic kidney disease, with a GFR of 13 ml/min/1.73m² according to the CKD-EPI equation. In the next six months, due to deteriorating renal function with uremic symptoms, the PD catheter was externalized, and PD was initiated after 4 weeks.

Within 48 hours after PD initiation, the patient presented with acute right-sided scrotal edema. CT-peritoneography was performed and revealed the recurrence of a right IH due to leakage of persistent dialysate fluid through a PPV (Figure 1).

His right IH was treated by open Lichtenstein TFMH (Figure 2), and PD was resumed 4 weeks after the operation. Currently, after 12 months of follow-up, the patient remains recurrence-free while on CAPD due to his preference.

Abdominal wall hernias are estimated to affect 4% to 14% of PD patients and are commonly caused by chronic high intra-abdominal pressure ³. When symptomatic, they may warrant interrupting PD until the problem is identified and resolved. If surgery is indicated, TFMH is the currently recommended treatment before resuming PD after a variable postoperative delay ²³. Unfortunately, undiagnosed IH may manifest primarily after PD initiation or rarely as a recurrence following previous TFMH ³. Our patient experienced the recurrence of right IH through a PPV after bilateral open IH repair using the Stoppa approach 6 months ago. Acute scrotal edema manifested within 48 hours after his first PD session, and PD had to be stopped. To our knowledge, such recurrence in a CAPD-ESKD patient has not been reported yet. The patient was offered open surgical repair with tension-free mesh placement using the Lichtenstein approach and resection of the herniary sac. The postoperative course was uneventful, and PD could be restarted 6 weeks after the surgery; a one-year follow-up found no herniary recurrence or related complications.

PD patients have a high risk of abdominal wall complications such as dialysate leak (5-10%), hernias (10-37%; mostly inguinal and umbilical hernias), or acute scrotal edema (2-4%) ⁴⁵. Acute scrotal edema is uncommon and often associated with an IH. There are risk factors for ESKD patients that may increase the likelihood of abdominal hernias (elderly males and those with polycystic kidney disease, previous hernia repair, midline incision for PD catheter placement, high BMI, greater residual volume, and prolonged PD duration are at greater risk) ³⁶⁷⁸. Additionally, the large volumes of fluid injected into the peritoneal cavity during CAPD may increase intra-abdominal pressure ³⁶⁷⁸ and force the fluid into the genitalia indirectly through an abdominal wall defect, or directly through an IH or PPV, causing scrotal edema ⁹. This process affects ultrafiltration efficiency and PD ³⁷. In adults, indirect IH is almost always congenital and attributed to a failure of PV closure ¹⁰¹¹. A small, indirect IH may unfortunately be missed before PD initiation and become clinically evident 3 to 105 months later ⁴¹⁰¹¹. When an IH is diagnosed before PD initiation, surgical treatment should be considered to prevent complications (decreased ultrafiltration efficiency, discomfort, recurrent peritonitis, incarceration, strangulation, necrosis, and perforation), particularly for irreducible hernias, considering that other hernias, such as reducible umbilical hernia, can still be managed conservatively in up to 71.42% of cases ³⁴⁷.

When indirect IH is suspected in an ESKD patient with PD and scrotal edema, CTperitoneography is considered the reference imaging study, considering its high detection rate ³. However, factors such as the risks associated with radiation exposure and allergy to contrast product may indicate other imaging studies such as abdominal ultrasound, peritoneal scintigraphy, or peritoneal magnetic resonance imaging ¹²¹³. Diagnostic laparoscopy may also help to confirm the diagnosis by excluding the possibility of a contralateral IH and a concomitant open repair with mesh ⁵. As of now, there is no consensus on the management of IH with scrotal edema in ESKD patients. Sometimes, a small indirect IH due to PPV can be treated conservatively with a 1-to-3week rest from PD or a temporary shift to HD or modified PD to decrease the volume of peritoneal fluid and intra-abdominal pressure ¹⁴. If surgery is indicated, the reference is open TFMH using the Lichtenstein technique ³¹⁵. However, recurrence occurs up to 60% of the time. Other TFMH techniques, such as an anterior, posterior (Stoppa technique), or laparoscopic approach, have been shown to have a low recurrence rate but a steeper learning curve ¹⁶. Hernioplasty is usually performed simultaneously with the placement of the PD catheter. In the literature, a posterior open approach for IH repair (the Stoppa technique) is indicated for patients aged over 50 with bilateral IH; this approach results in a low recurrence rate of 0.7% ¹⁷¹⁸. However, as the mesh retracts by up to 20% over 6 months, an insufficiently large mesh may trigger recurrence ¹⁹. In a case series involving 14 patients, the Lichtenstein procedure with sac excision was associated with a good outcome. No PD-related complications were observed, and no recurrence was observed during a follow-up after about 3 and a half years ²⁰. In our patient, the right IH reappeared after Stoppa hernioplasty and was treated by TFMH using the Lichtenstein approach without recurrence. Postoperatively, increased intra-abdominal pressure and chronic renal failure may impair tissue healing, and the optimal timing for PD reinitiation remains undefined ³⁴.

PD is usually restarted at normal volumes within 2-4 weeks; during this interval, lowvolume PD is used with frequent exchanges, which are gradually increased to regain the preoperative CAPD regimen ³⁴.

Despite some conflicting data on the association between intraperitoneal volume infusion and intraperitoneal pressure ²¹, automated peritoneal dialysis (APD) using smallervolume dwells while the patient is recumbent during the night is an attractive approach in these situations. Indeed, supine exchanges have been associated with decreased intraabdominal pressure per volume of dialysate (as intraperitoneal pressure parallels intraperitoneal volume) with similar efficacy to other techniques ²².

Thus, APD has been used effectively in place of CAPD in ESKD patients who develop abdominal wall hernias ³⁴⁷¹⁴. Interestingly, laparoscopic transabdominal preperitoneal (TAPP) IH repair may decrease morbidity and the recurrence rate compared to open surgery and PD resumption after 7 days ²³. In our case, PD was restarted with normal volumes after 6 weeks when the surgical wound had completely healed. Despite our short follow-up interval of 1 year, the patient remains recurrence-free, in line with the low recurrence rate reported in the literature ³.

In conclusion, TFMH should always be proposed before PD in ESKD patients when IH is diagnosed. The recurrence rate of IH after Stoppa bilateral TFMH is as high as 1.7%, and factors such as the failure to diagnose occult PPV before the initiation of PD may trigger this recurrence ¹⁹. Scrotal edema arising after PD initiation suggests the existence of an indirect IH and potentially a PPV. Different imaging studies may help with the diagnosis depending on the context, but a CT-peritoneogram is still considered the reference. The surgical correction of the primary or recurring IH should not be delayed, allowing PD reinitiation as soon as possible.