多発性子宮筋腫に対する子宮全摘術後に左尿管損傷と膀胱腟瘻を併発した1例

Abstract

42歳女.多発性子宮筋腫で子宮全摘術を施行されたが, 1週後に下腹部痛が出現し, 骨盤部CTで後腹膜に液体貯留を認めた.IVPで左水腎と下部尿管の閉塞及び造影剤の尿管外流出を, 膀胱鏡で三角部後方に粘膜の浮腫状膨隆と引き連れを認め, 膀胱腟瘻を考えて左経皮的腎瘻造設術を施行した.ドレーンよりの液体流出が減少したため抜去したが, 尿失禁が出現し, 膀胱鏡で三角部後方に3ヶ所の瘻孔と結紮された絹糸及び乳頭状の粘膜病変を認めた.炎症の消退を待って膀胱尿管新吻合, 膀胱腟瘻修復術を施行した.左尿管は総腸骨動脈分岐部以下で周囲と癒着し剥離困難であったため, この部位で切断した.膀胱を正中で縦切開し, 膀胱腟瘻まで切開線を延ばし, 左右の膀胱弁に分けた.膀胱後壁と腟前壁を剥離し, 膀胱腟瘻を切除して腟壁を閉鎖後, 左膀胱flapと左尿管を新吻合し, psoas hitch法で腰筋に固定した.術後20日目に左水腎はほぼ消失し, 膀胱機能も良好に保たれた

A 42-year-old woman underwent total hysterectomy for multiple myoma uteri. Postoperatively the patient complained of lower abdominal pain and total incontinence. She had also developed left-sided hydronephrosis. Left nephrostomy was constructed and necessary investigations were done. It was diagnosed as a case of left ureteral injury with vesico-vaginal fistula. Repair of vesico-vaginal fistula and reimplantation of the left ureter were performed in a single setting three months after the injury. Subsequently, the nephrostomy was removed. Hydronephrosis was improved with an excellent outcome of fistula repair.