腹膜襞形成と性腺血管を支えとした腹膜外 側合流式無管尿管皮膚瘻術―

Abstract

正常尿管や腹壁脂肪組織の厚い症例の一側合流式無管尿管皮膚瘻術が成功するよう, 次のような工夫をした. 1)腹膜に襞を形成し索を支えとして, 後腹膜腔から最短距離で腹膜外にストーマへ到達する路を造った.それに依って尿管の上下方向の張力を減らし, 正常尿管でも良好な血流が得られる様にした. 2)皮下脂肪の厚い症例でも血行ある索で脂肪組織を被うことによって尿管の着生を促した. 3)有茎皮膚弁形成後の拡大した欠損部を十分に縫縮し, ストーマを形成する弁状の尿管壁に左右方向への張力がかからないようにした.尿管先端の張力を減らすことによって, 血流障害を防いだ.この術式を行った正常尿管16例の短期観察で10例は成功した.4例は1腎が正常で他腎は軽度から中等度の水腎を, 残り2例は1腎は正常で他腎は無機能腎であった.1例を除いてBUNやCr.は正常で, 全例Tubelessの状態で日常生活を送っている

Tubeless cutaneous ureterostomy through a single stoma has been said to be difficult to establish in patients with normal ureters or normal ureters combined with thick fatty abdominal wall, because of the poor blood supply at the end of the ureters. The technical improvements observed were as follows: 1) The peritoneal fold and the upward traction of the gonadal vessels decrease the ureteral tension and keep the blood supply to the ureters in the extraperitoneal approach. 2) The gonadal vessels and its surrounding tissue, covering the subcutaneous fatty tissue, help the ureteral adhesion at the anastomotic site. 3) Full diminution of the skin defect caused by flap formation, decreases the horizontal tension of the side-to-side anastomized ureters. Sixteen patients with normal ureters underwent this procedure. In a short-term (4-37 months) observation, 4 of the patients, including one with thick abdominal fat, showed unilateral hydronephrosis and 2 patients unilateral non-function kidney. The remaining 10 patients had no complications. Moreover, all the patients have kept their ureterostomies tubeless and their serum blood urea nitrogen and creatinine levels were within normal limits except for one patient. It is reasonably concluded that the new method will result in success clinically even in patients with normal ureters and thick abdominal fatty tissue.