尿管鏡による医原性尿管断裂に対して保存的治療が可能であった1例

Abstract

52歳女。患者は顕微鏡的血尿に対する精査目的で著者らの施設へ受診, 左尿管結石と診断され, 経尿道的尿管結石破砕術が施行された。しかし破砕中, 結石が腎盂にpush upされ, 再度腎盂内で破砕が行われた。そして破砕終了後, 外尿道口には断裂した尿管が確認され, 術後6週目に膀胱鏡が施行された。その結果, 断裂し突出した尿管は壊死に陥りほぼ全て石灰化していた。治療として壊死尿管切除術を施行したところ, 術後, 残石の自然排石がみられ, DIPでは水腎症を認めなかった。以後, 2ヵ月経過の膀胱鏡検査では尿管口は狭窄を認めず, ほぼ正常に修復していた。

A case of ureteral avulsion as a complication of ureteroscopy is presented. A 55-year-old woman was admitted to the hospital with the complaint of hematuria. The intravenous pyelography revealed a calculus measuring 16 x 12 mm located in the left upper ureter. Transurethral ureterolithotripsy was performed with 8 F rigid ureteroscopy. A safety guide wire was inserted and left ureteral olifice was dilated to 9 F. The ureteroscopy was smoothly introduced just under the stone. The stone was fragmentated with a pneumatic lithotripter. A part of the stone was pushed back to the renal pelvis, so the ureteroscope was passed to that stone and fragmentation was done as much as possible. The ureteroscopy was gently pulled out to the bladder, but the distal ureter was torn at the ureteral orifice and could be seen at the urethral orifice. Pelvis, upper ureter and middle ureter were intact, so open intervention for repair was not performed. A 6Fr double pigtail stent was placed over the safety guidewire. Cystscopy indicated a part of the distal ureter was protruded from the ureteral orifice. Eight weeks later, the protruded part of ureter was necrotic and calcified for ischemia. Transurethral resection of necrotic ureter was performed. Histologically, resected ureter changed necrotic tissue for ischema. Postoperatively intravenous pyelography did not reveal left hydronephrosis and cystoscopy indicated that the left ureteral orifice was almost normally repaired.