膀胱自然破裂により発見された膀胱扁平上皮癌の1例

Abstract

A-90-year-old woman visited complaining of nausea, vomiting, and abdominal pain. She had abdominal rigidity and signs of generalized peritonitis. On computed tomography (CT) gastrointestinal perforation was denied and irregular thickness of the bladder wall was pointed out. Cystography was performed, but bladder rupture was not confirmed. Post-cystogram-CT revealed the leakage of contrast material in the peritoneal cavity from the urinary bladder. Spontaneous intraperitoneal bladder rupture was diagnosed. Cystoscopy was performed, but no information could be obtained due to severe cloudy urine. Open laparotomy was performed. At surgery, cloudy fluid was aspirated from the abdominal cavity. Abdominal organs were normal when explored, but a small perforation was found on the vault of the bladder and primary closure was performed. Postoperatively, cystoscopy was performed again after the medication with antibiotics. A huge, nonpapillary tumor was seen on the left lateral wall. Tumor biopsy was performed. Histological examination of specimens revealed squamous cell carcinoma. On abdominal CT, invasive bladder carcinoma, left hydronephrosis and hydroureter were pointed out. Considering her age, general health status and prognosis, only right ureterocutaneostomy was performed.

90歳女。嘔気嘔吐、腹痛の出現で腹膜炎を疑われ紹介入院となった。腹部板状硬で圧痛があり、導尿にて混濁尿を認め、造影CTで左水腎水尿管および膀胱壁不整肥厚を認めた。単純CTで腹腔内造影剤貯留を認め腹腔内膀胱破裂と診断し、緊急膀胱修復術を施行した。腹腔内は混濁尿で汚染され、小穿孔部を認めた膀胱頂部は炎症により組織が脆弱化し、膀胱は全体に硬化していた。術後の持続ドレナージおよび抗生剤投与により腹膜刺激症状は軽快し、尿混濁も改善した。膀胱鏡の施行で左側壁を中心に後壁、頂部にかけて一部壊死を有する巨大腫瘍を認め、造影CTで左側壁中心に浸潤する腫瘍を認め、生検病理所見より扁平上皮癌と診断した。年齢、全身状態、performance status grade 4、既往(心不全、喘息)、予後を考慮して尿路変更の右尿管皮膚瘻造設術のみ施行した。悪性腫瘍の進行、誤嚥性肺炎などによる全身悪化で入院後約4ヵ月目に死亡した。