膀胱結石を伴った膀胱癌による膀胱回腸瘻の1例

Abstract

66歳男。便秘で下剤を服用したところ、10日間下痢が続き排尿時痛も現れたため受診した。腹部CTで長径約4cmの大きな膀胱結石を認め、血液検査で高度な炎症所見を示し、尿中白血球は100以上/HPFであり、膀胱結石、尿路感染症の診断で入院となった。膀胱造影で膀胱小腸瘻と診断し、瘻孔は大きく栄養状態が不良なので、保存的閉鎖は期待できないと判断し開腹手術を実施した。術中所見は膀胱頂部と回盲部から50cmに回腸とS状結腸が癒着し一塊になっており、瘻孔部はもろく周囲の腸間膜には腫大したリンパ節を認めた。小腸、S状結腸、膀胱部分切除により瘻孔部を摘除した後、両側尿管皮膚瘻による尿路変更を行った。摘出標本の病理所見は膀胱由来の扁平上皮化生を伴う浸潤性尿路上皮癌であった。術後2ヵ月目に残存膀胱の腫瘍腫大とそれに伴う疼痛が認められ、術後4ヵ月目には腹部・骨盤部のリンパ節腫大を認め、術後5ヵ月で癌性悪液質にて死亡した。

Enterovesical fistula is a very rare complication of primary urological malignancies. A case of ileovesical fistula caused by a bladder carcinoma is presented. A 66-year-old male was referred with complaints of urinary pain. On admission, fecaluria and urinary tract infection with bladder stone were detected. Cystography revealed the passage of contrast medium into the small bowel. Under the diagnosis ofileovesical fistula due to suspected inflammatory disease, sigmoidectomy and segmental small bowel resection with partial cystectomy were performed. Histological evaluation revealed a poorly differentiated urothelial carcinoma. Without further treatment, the patient died from cancer five months after operation. However, it is hard to assess the effect of fistulas on prognosis. Since it has been reported that about 40% of the patients with T4 bladder tumors could be potentially cured with radical resection, we recommend a thorough examination to confirm the diagnosis of primary disease to obtain the best results.