異常血管による下部尿管通過障害の1例

Abstract

A case is a 39-year-old female, who visited our clinic with the chief complaint of left flank pain. A plain film of the abdomen showed no calculus. An excretory urogram demonstrated marked dilatation of the left renal pelvis, upper and middle ureter, but the lower ureter appeared normal. In the retrograde study catheter could be inserted only 8 cm from the left ureteral orifice. The aberrant blood vessels are small two arteries branching from the internal iliac artery and oppressing the left lower ureter anteriorly about 6 cm above the ureterovesical junction. Therefore we ligated and dissected these blood vessels together with ureterolysis. Excretory urogram taken 6 months after surgery revealed remarkable improvement of left hydronephrosis. No complaint has occurred since surgery. Congenital ureteral obstruction due to compression from vascular anomaly is rather rare and especially those occurring at the lower ureter are very rare. 101 cases of hydronephrosis due to aberrant blood vessels were collected from the literature since 1955, 58 being male and 42 female. Side of vascular obstruction was right in 38 cases, left in 56 cases and bilateral in one. The average age of the collected 101 cases was 27. Among these 101 cases of the vascular obstruction, only 10 cases including our case occured at the lower ureter, 2 being male and 8 female. A higher incidence among the female was noted. In 4 cases, ureteral obstruction was relieved with dissection alone of the aberrant blood vessels with adhesive fibrous band, but the other 4 cases were treated by resection of constricted portion of the ureter and ureteroneocystostomy. In one case, vascular dissection with reimplantation of the ureter was performed and in the last one, ureterolithotomy alone was carried out. It is rather difficult to diagnose these vascular obstruction of the lower ureter preoperatively. The most useful technique may be angiography in combination with pyeloureterography. However, preoperative diagnosis of the aberrant blood vessels would not be required, only the adequate treatment would be taken at the time of operation. Concerning with hydronephrosis by aberrant blood vessels, Campbell presented the idea that those vessels must have been rather secondary cause than primary and the accumulation of other factors such as renal ptosis, vigorous body movement may have lead to the manifestation of hydronephrosis. But we think that in the lower ureter those factors other than aberrant blood vessels would not contribute to the obstruction. This conception serves to determine whether ureteral transsection and reimplantation is needed or vascular resection with ureterolysis only is sufficient. In addition to this idea, we should consider changes in the ureteral wall, peristaltic alteration of the upper ureter and the degree of dilatation, to decide if the resection alone of the aberrant blood vessels results in success or failure.