尿路変向術の術後ケアーの諸問題 : Ureterocutaneostomy

Abstract

尿管皮膚瘻施行109例について検討を行った. 1)術後のtubeless成功率は全体で66%であり, Stomaの形成方法では, everted nipple法によるもの, 又, 術前に尿管の拡張がみられる症例で成功率が高い傾向にあった. 2)tubeless成功例では, 術後尿感染の発生が少なく, 腎盂腎炎, 腎結石などの尿路合併症の発生も低い傾向にあった. 3)尿管皮膚瘻術は, 回腸導管などの他の尿路変向術と比較して, 術後の腎機能の面でも問題はなかった. 4)尿管皮膚瘻術は, 拡張及び肥厚した尿管を有する症例に対して施行されるのが適切であるが, poor riskの症例, などでは, 正常尿管であっても, 本術式の適応として, 積極的に行うべきと思われた

One hundred and nine patients underwent tubeless ureterocutaneostomy as a method of urinary diversion at the Department of Urology, Wakayama Medical College during the 22 years from 1972 to 1994. The follow-up period ranged from 4 days to 15 years, with a mean of 27.3 months. The primary disease was bladder cancer in 68 patients, uterine cancer in 23 patients, other pelvic malignancies in 11 patients and benign disease in 7 patients. We used 4 types of ureterocutaneostomy; transureteroureterocutaneostomy was done in 13 patients, bilateral ureterocutaneostomy through a single stoma in 30 patients, bilateral ureterocutaneostomy with two stomas in 4 and unilateral ureterocutaneostomy for one available kidney in 62 patients. The construction of stoma was done according to inverted U of Z-shaped skin flap method (30 cases), everted nipple stoma (37 cases) and Toyoda's method (42 cases). We evaluated the stomal condition in 72 patients who were followed more than 6 months postoperatively. Stomal stricture developed and necessitated periodic dilatation or intubation in 25 cases (34%). A better outcome was obtained in patients with dilatated ureter and everted nipple type stoma but no correlation could be found between the history of irradiation and stomal stricture. Long-term outcome of ureterocutaneostomy in 70 patients (129 renal units) was, compared to that of ileal conduit urinary diversion in 124 patients (248 renal units). Postoperative urographic findings showed progressive hydronephrosis in 14 renal units (23%) in the ureterostomy group, while 22 renal units (9%) in the ileal conduit group. However, there was no case of deterioration of renal function which was evaluated by BUN and creatinine in spite of progression of hydronephrosis. The incidence of urinary complications such as pyelonephritis and renal calculus in the successful ureterocutaneostomy group was less than that in the ileal conduit group.