人工的に発生させた水腎症による膀胱全摘・回腸導管造設術後の両側上部尿路上皮内癌の診断と治療

Abstract

75歳男.肉眼的血尿・膀胱刺激症状が出現した.尿細胞診はhigh grade TGGで, 経尿道的膀胱腫瘍切除術後, 患者・家族の希望により膀胱・前立腺・尿道全摘, 回腸導管造設術を行った.術後26ヵ月目, 回腸導管尿細胞診でurothelial carcinomaを認めた.IVP, 腹部CTでは, 両側とも水腎症を認めず, passage良好で, 両側上部尿路, 及び回腸導管内に異常所見はなかった.人工的に水腎症を発生させて腎瘻を留置し, 分腎尿細胞診を行った.その結果, 両側にurothelial carcinomaを認め, 両側上部尿路上皮内癌の診断で経皮的Basillus Calmatte-Guerin(BCG)灌流療法(左腎盂:計5回, 右腎盂:計6回)を行った.BCG灌流療法開始後4ヵ月目, 回腸導管尿細胞診は陰性化した.膀胱全摘・回腸導管造設後の導管尿細胞診陽性症例に対し, 人工的に水腎症を発生させて腎瘻を留置することは上部尿路再発の診断・治療に有用であると思われた

We report the diagnosis and treatment for carcinoma in situ of the bilateral upper urinary tracts after total cystectomy and ileal conduit by intentionally inducing hydronephrosis. A 75-year-old man whose chief complaints were macroscopic hematuria and bladder irritabilities was diagnosed carcinoma in situ of the bladder and underwent total cystectomy and ileal conduit. 26 months after the operation, the cytological examination of ileal conduit urine revealed urothelial carcinoma. Since the radiographic findings in the upper urinary tracts and ileal conduit were negative, we constructed bilateral percutaneous nephrostomies by intentionally inducing hydronephrosis. Since two serial cytological examinations of the urine sampling from the bilateral pyeloureteral systems revealed urothelial carcinoma, we performed the percutaneous Bacillus Calmatte-Guerin perfusion of the bilateral upper urinary tracts. The therapy was repeated at weekly intervals for a total of 11 perfusions and the cytological examination of ileal conduit urine became negative 4 months after the beginning of the therapy. Intentionally induced hydronephrosis is useful for the diagnosis and treatment for carcinoma in situ of the bilateral upper urinary tracts after total cystectomy and ileal conduit.