経尿道的処置により管理しえた腎乳頭壊死の1例

Abstract

66歳女性.発熱, 右側腹部痛を主訴として来院し, 内科にて右水腎症及び腎機能低下を指摘され泌尿器科に紹介された.右逆行性腎盂造影(RP)では上腎杯部は形状が失われ鈍化し, 下部尿管内に陰影欠損を認めた.ドレナージのために右尿管にステントを留置したところ, 全身状態の改善を認めた.3週後, 再度RPを施行した.1回目のRP時に認めた陰影欠損は上部尿管に移動し, 全体的に縮小していたが, 持続する尿管閉塞に対し, 尿管鏡検査を施行した.尿管内に浮遊する8mm大の黒褐色の組織片を2個認め, これを鉗子で摘出した.病理組織は壊死した移行上皮組織で, 腎乳頭由来と考えられた.4ヵ月後, 左上部尿管に同様のエピソードが見られたため, 同様の処置を行った.摘出10ヵ月後の現在, 水腎症は認めていない

The patient was a 66-year-old female who had been commonly using an analgesic for rheumatism from age 40. She visited our hospital with the complaints of fever up and right flank pain. Right hydronephrosis and renal failure were pointed out, and she was referred to the urologic clinic. Retrograde pyelography showed a clubbed upper calyx and filling defect in the lower ureter. A ureter stent was positioned for drainage in the right ureter. Then her general state improved. Three weeks later, retrograde pyelography was performed again. Two filling defects were detected in the upper ureter. Since the obstruction persisted we observed the ureter by ureteroscopy. Two specimens black-brown in color and 8 mm in diameter were observed through the ureteroscope and were removed with a basket catheter. Histological examination of the specimens revealed necrotic transepithelial tissues. It was assumed that the tissues were derived from necrotic renal papilla. Four months later, a similar episode was observed in the left upper urinary tract. The same procedures were performed to manage the patient. In this case, drainage using a ureter stent was effective and conservative therapy was possible. This is the first reported case of renal papillary necrosis managed by transurethral procedures in Japan.