Search

We present a rare case ofcolonic adenocarcinoma occurring in an Indiana pouch. A 68-year-old man underwent radical cystectomy with Indiana pouch urinary diversion for the treatment of bladder cancer 16 years ago. He was referred to our hospital for the treatment of a right staghorn stone, left renal stone, and pouch stones. Cystoscopic findings showed a 10×10 mm tumor distal to ureter anastomosis. Under the diagnosis of colonic adenocarcinoma in an Indiana pouch, tumor and stones were successfully removed. Adenocarcinoma occurrence after ureterosigmoidostomy is well-known. However, diagnosis of adenocarcinoma in an Indiana pouch isextremely rare.

平成4年4月に手術した73歳男で, 組織学的にグレード3のTCC(移行上皮癌)であった.5年2月に肉眼的血尿を訴え, 静脈性腎盂造影で無機能右腎及びインディアン・パウチ内陰影欠損を認め, 血清CEA(癌胎児性抗原)・CA19-9値上昇のため, パウチ内結腸癌を疑った.パウチ内腫瘤の内視鏡的生検によりグレード2TCCと判明した.5年7月に右腎, 尿管, 及びパウチを一塊として摘出した.右腎・尿管の癌はグレード2TCCと診断された.術後21日に血清CEA・CA19-9値は正常範囲に戻った.右腎・尿管癌は組織化学的染色でCEA・CA19-9陽性であった.膀胱腫瘍でもCEA・CA10-9陽性細胞を認めた, A 73-year-old female with transitional cell carcinoma (TCC) of the bladder underwent total cystectomy and Indiana pouch replacement in April, 1992. Histological examination revealed grade 3 TCC. In February 1995, she complained of gross hematuria. Intravenous pyelography (IVP) revealed a right non-functional kidney and filling defect in the Indiana pouch. We suspected colon cancer in the Indiana pouch because the levels of serum carcino-embryonic antigen (CEA) and CA19-9 were elevated. Endoscopic biopsy of intrapouch tumor was done. Pathological examination revealed grade 2 TCC. In July 1995, right nephroureterectomy with resection of Indiana pouch was performed and the surgical specimen revealed renal pelvic and ureteral cancer, grade 2 TCC. The levels of serum CEA and CA19-9 returned to the normal range 21 days after the operation. CEA and CA19-9 histochemical stain of renal pelvic and ureteral cancer were positive. Also CEA-, CA19-9-positive cells were detected in the specimens of the bladder tumor from the total cystectomy performed in 1992. This rare case is discussed and the literature is reviewed.

73歳男.12年前に膀胱全摘+インディアナパウチ造設術を施行した.9年前, インディアナパウチ内に結石を認めたため体外衝撃波結石破砕術(ESWL)を8回施行し完全排石を得た.4年前, 結石の再発を認め, ESWLを計22回施行したが排石はほとんど認められず, 経過中結石が増加・増大傾向を示したため手術を行うこととした.ストマロより16Frのネラトンカテーテルをパウチ内に挿入し, これに沿ってガイドワイヤーーをパウチ内に留置した後, アンプラッツダイレーターで26Frまで拡張し, 外筒を留置した.生理食塩水をパウチ内に注入し, 用手的に腹部を圧迫し排水するという作業を繰り返すことで約8割の排石が得られた.残石は腎盂鏡下に超音波砕石器を用いて破砕し, 1個を除いて除去された, A total cystectomy with the Indiana continent diversion was performed on a 73-year-old man under the diagnosis of invasive bladder cancer in 1992. In 1994 there appeared a few urinary stones in his Indiana continent urinary diversion. Extracorporeal shock wave lithotripsy (ESWL) was successfully performed. In 1999 a few urinary stones recurred and ESWL was performed. Stones could not be discharged because of stricture of the efferent limb, although stones were crushed down into small pieces by repeated ESWL. The number and sizes of stones gradually increased. Dilatation of the stoma followed by a trans-stomal operation was performed and all of the stones except for one were extracted.

1)Kock pouch(K群) 124例, Indiana pouch(I群) 51例, 虫垂臍ストーマMainz pouch(M群) 4例について検討した. 2)手術関連死はK, I群各2例であった.早期合併症は創感染15例, イレウス5例にみた. 3)晩期合併症は, K群(108例)で輸出脚不全18例, 輸入脚不全23例, ストーマ狭窄7例等, I群(47例)では, ストーマ狭窄3例, パウチ変形, 導尿困難各2例であった. 4)晩期合併症に対する修復再手術は, それぞれ22例, 5例に施行された. 5)結石形成は, K, I群でそれぞれ30例, 3例であった. 6)M群では晩期合併症は認めていない. 7)尿禁制はK, I, M群でそれぞれ90.2, 93.0, 100%で得られ, 水腎症はそれぞれ41.0, 9.5, 0%にみられた, A self-catheterizable continent urinary reservoir has become one of the major options for urinary diversion in patients with invasive bladder cancer or other pelvic malignancies. We performed the Kock pouch, the Indiana pouch and the appendiceal Mainz pouch in 124, 51 and 4 patients with the mean followup periods of 50, 33, and 10 months, respectively. In the Kock pouch, the efferent and afferent nipple valve malfunction was seen in 16.7 and 21.3 percent each, requiring repair surgery, such as fixation of the efferent nipple to the pouch wall, reconstruction of an isoperistaltic nipple valve in the former, and removal of the Dacron fabric collar or re-anastomosis of the ureter to the pouch using LeDuc technique in the latter. In the Indiana pouch, stomal stenosis, an hourglass-like pouch deformity, difficult catheterization occurred in 3, 2 and 2 patients, respectively. Among the 4 patients with the appendiceal Mainz pouch, there were no major late postoperative complications except for mild stenosis of the conduit, handled with bougienage. As a whole, surgical revisions, related to urinary diversion, was done in 20.3, 10.6, 0 percent in the Kock, Indiana, Mainz pouch patients, respectively. Stone formation, mostly multiple and recurrent, occurred in 27.8, 6.4, 0 percent in the Kock, Indiana, Mainz pouch, respectively. Most of the stones were removed endoscopically via a stoma or by percutaneous approach. Acidosis was seen in 3 patients in both the Kock and Indiana pouch, and 3 patients with the Kock pouch suffered from symptomatic choleithiasis. At the time of the latest observation, continence was achieved in 90.2, 93.0, and 100 percent, whereas excretory urograms showed normal collecting systems in 64.5, 90.4, and 100 percent in the Kock, Indiana, and Mainz pouch, respectively. In conclusion, the Kock pouch, performed by an original method using unabsorbable polyester fabric collars and metallic staples, has an intolerably high rate of late complications, and either the modified Indiana pouch with ileal patch or the appendiceal Mainz pouch using the umbilicus as a stoma is recommended for a self-catheterization continent urinary diversion.

1)Kock pouch12例, Indiana pouch14例の手術成績について検討した. 2)術後合併症のおもなものはkock pouchで結石形成(5例), Indiana pouchで初期症例における創感染(4例)及び導尿困難(4例)などであり, 特にKock pouchの異物結石の形成は大きな問題であった. 3)術後のアシドーシスを認めた症例は2例のみであった.又, 何れの術式でも正常範囲内ではあるが有意の血中尿素窒素の上昇, 尿中pHの上昇を認めた. 4)26例中22例に無症候注の持続する細菌尿を認めたが, 膿尿を認めた症例は5例のみであった, The Kock continent urinary reservoir was constructed in 12 patients from 1988 to 1990 followed by the Indiana continent urinary reservoir in 14 patients thereafter. There were no perioperative death in either group. The period of postoperative follow-up was 11 approximately 70 months, with a mean of 58.9 months. Several modifications of the operative technique were made to the original Kock pouch, but stone formation was observed in 5 patients (42%), resulting from foreign materials permanently in contact with urine. In the Indiana pouch group with a mean postoperative follow-up period of 26.8 months (range 11 approximately 43 months), wound infection occurred in the initial 4 patients and difficulty of catheterization in the other 4 patients. The serum electrolyte values were found to be within the normal limits during the follow-up period in both groups, but, mild acidosis occurred in 2 patients. Patients with urinary diversion demonstrated mild azotemia (P = 0.02) despite similar serum creatinine levels and an increase in urine pH (P = 0.006) postoperatively. Asymptomatic bacteriuria was demonstrated in 22 of the 26 (83%) patients with the reservoir, but only 5 patients had significant pyuria. Our clinical experience suggests that the Indiana pouch is a more reliable method than the Kock pouch to construct a continent urinary reservoir.

1)非失禁性代用膀胱(Kock pouch, Indiana pouch)を造設した患者の術後の生活の質(QOL)を調査した。2)81例に106項目の質問用紙を郵送し, 自記式にて60例(74%)の症例より回答をえて分析対象とした。3)1回導尿量は約400mlで約4時間毎に導尿している。夜間導尿回数は1.2回である。4)肉体的健康状態や精神的健康状態はおおむね良好に保たれていた。5)ストーマを見られることを嫌うために, 家族と入浴することは少ないものの, 59%が公衆浴場にも行っていた。6)睡眠時には80%がストーマを気にしていなかった。7)社会生活に関するQOLでは, 交友関係, 運動や趣味においては20～30%の患者に悪影響があったが, 術前仕事をしていた患者の22%が術後仕事を止めていた。術後, 旅行を断念した者は少数であった。8)性生活に関しては, 術後勃起力の低下が著しく, 従って性生活はきわめて惨めであり, 勃起力を維持した術式の応用が望まれた。9)手術と関連した症状として, 皮膚の異常はあまり認められなかった。10)質問用紙中の簡単な説明のみの理解であったが, 再度尿路変更術をしなければならないとすれば, 同じ術式を選択すると答えたのは94%であった, To improve the quality of life (QOL) of patients requiring urinary diversion, various surgical techniques including those employing a continent urinary reservoir (CUR), such as Kock pouch or Indiana pouch, and those using the conventional ileal conduit have been advocated. In this study we asked patients who had undergone a CUR operation to complete a questionnaire, consisting of 106 questions relating to the QOL during the disease-free period. A total of 81 questionnaires were sent out, and 60 (74.1%) CUR patients responded. The average age was 61 and the male to female ratio was 49 to 11. The time elapsed from the operation was 42 months. Twenty-nine questions addressed the patients physical condition and on the whole it was kept in good quality. Because they were unwilling to show their stoma, they were reluctant to bathe together with family members. However, 59% of them went to a public bathhouse (common in Japan). Other physical abilities related to exercise were not significantly hampered by this operation. Eighty per-cent of them were not bothered by having a stoma. Twenty four questions were related to social life. The operation had a bad influence in 20-30% of them concerning their interaction with friends and hobbies. Twenty two percent of the patients who had a job prior to the operation stopped working. Only a few patients abandoned travelling. Concerning their sex life (7 questions), males suffered impotence at a very high rate, but only 26% of the patients lost interest in sex. Symptoms related to the operation (41 questions) were mild. Overall, 94% of the patients would choose the same operation again if it were required.(ABSTRACT TRUNCATED AT 250 WORDS)

1987年7月～1988年11月の間にkock回腸膀胱造設を39～76歳の11例(K群), 1989年7月～1991年3月の間にIndiana pouch造設を44～66歳の9例(I群)に行った.I群の最初の4例にileal patch変法, 後の5例にHeineke-Mikulicz法を行った.一期的根治的膀胱摘出兼尿路変更を19例に行い, 1例で両側尿管皮膚瘻からkock回腸膀胱に変えた.周術期死亡はないが, 各群の各1例でパウチ縫合不全に対し再手術を行った.K群では, 輸出脚の弁不全の1例に輸出脚形成術を行い, 又, 輸出脚脱出を2例, 輸入脚の弁不全を2例にみた.I群では, 1側水腎症を1例, カテーテルの挿入困難を4例にみた.両群の3例で軽度の失禁をみたが, パウチ容量は500 ml以上で, 腎機能もquality of lifeも良い, Recently, the continent urinary reservoir which provides the patient with a better quality of life has become popular. Many types of reservoirs have been reported, but the optimal procedure remains to be established. From July 1987 through November 1988, we performed Kock pouch construction on 11 patients (ages 39 to 76 years). Between July 1989 and March 1991, 9 patients (ages 44 to 66 years) underwent Indiana pouch operation. The first 4 patients underwent ileal patch type, and the subsequent 5 underwent Heineke-Mikulicz type procedure. A one-stage radical cystectomy and continent urinary reservoir construction was performed on 19 patients, and bilateral cutaneous ureterostomy was converted to Kock pouch in one patient. There were no perioperative deaths, but reoperation was required for urinary leakage from the reservoir on one patient in each group. As the late complications in the Kock pouch group, one patient required revisional operation of the continent valve mechanism, 2 patients experienced intermittent prolapse of the nipple valve of the efferent limb, and 2 had malfunction of the afferent nipple valve. In the Indiana pouch group unilateral hydronephrosis was noticed in one patient, and 4 had mild difficulty of catheterization. Although 3 patients in both groups had mild urinary leakage, all patients had good quality of life with capacity of reservoir over 500 ml and with good renal function. We changed the type of operative procedure from Kock pouch to Indiana pouch because of the high complication ratio in the former.(ABSTRACT TRUNCATED AT 250 WORDS)

1) 1987年10月より1991年9月までにIndiana pouchによる尿路変更手術を39例に施行した.2)この間に, 結腸の完全なdetubularization, stapled plication, U-shaped ileal patch法などの手技の改良を行った.3)早期合併症は開放手術に共通する一般的なもので, continent urinary reservoir (CUR)に直接関連したものはなかった.4) 3ヵ月以上経過観察された37例の晩期合併症のおもなものは, pouch変形(2例), 導尿困難(2例), ストーマ狭窄(2例), アシドーシス(1例)などであった.5) 90%以上の症例で良好な尿のコンチネンスがえられ, 尿管への逆流を認めたものはなかった.6)本術式は, 術式が比較的簡単で重大な合併症も少ないことから, 今後もきわめて有用なCURであると考えられた, From October, 1987 through September, 1991, 39 patients underwent construction of Indiana pouch for cutaneous urinary diversion. There were 35 men and 4 women, and their ages ranged from 38 to 77 years (a mean age of 62 years). After the first 8 cases, Indiana pouch was constructed with several modifications which included complete detubularization of the cecum, construction of the pouch augmented with U-shaped ileal patch, and the use of stapled plication. There was no major early complication related to the pouch but one postoperative death of blood transfusion related graft versus host disease. End results were evaluated in 37 patients who were followed for 3 to 49 months. Late complications related to urinary reservoir occurred in 8 patients. The early two patients experienced pouch deformity due to incomplete detubularization of the colonic segment. Two patients had difficult catheterization due to a dilatation of the plicated ileum. One patient had metabolic acidosis requiring hospitalization. Patients perform self-catheterization 4-5 times during the day and 0-2 times at night for volumes ranging from 300 to 1, 000 cc. Of 37 patients 34 achieved acceptable urinary continence and one had significant leakage requiring cutaneous bag. The remaining two patients suffered mild nocturnal incontinence. Follow up examination with excretory urography showed no upper urinary tract obstruction except one with unilateral hydronephrosis due to ureteroanastomotic stricture. Reservoirgraphy showed no reflux into the upper urinary tract in all the follow up cases.(ABSTRACT TRUNCATED AT 250 WORDS)

1) GURが導入されて以来, 浸潤膀胱癌全摘に伴う尿路変更で全体の45%にCURが選択されている.2) Kock pouch 100例の成績からみると, 術後比較的早期にみられる輸出脚合併症は手術手技の改良で克服できたものの, より長期の観察でカラーに起因した輸入脚合併症と結石形成が増加している.3) Indiana pouch 30例の成績からみると, ileal patch法の方がHeineke-Mikulicz法よりも安定した成績を挙げており, CURの第一選択と考えられる.4)ハンモック法による回腸尿管吻, Continent urinary reservoirs (CUR) have become one of the major options of urinary diversion for invasive bladder cancer patients who require cystectomy and cutaneous urinary diversion. We have experienced 100 cases of Kock pouch and 30 cases of indiana pouch during the past 5 years which comprise 45% of all cases. Standard ileal conduit and ureterocutaneostomy were performed in 34% and 20%, respectively, and orthotopic urinary reservoir by hemi-Kock pouch was done in only one case during the same years. There were 3 perioperative deaths, 2 had Kock pouch and one Indiana pouch. Early postoperative complications were not substantial. However, significantly high rates of late postoperative complications were seen in Kock pouch, i.e., both efferent (18%) and afferent (13%) nipple valves and stone formation (18%). Uretero-ileal anastomosis by hammock method done in 10 cases resulted in success in 8 cases, abolishing the afferent nipple. Indiana pouch, in which no nipple valves or foreign materials like staples or collars are necessary, has been adopted as a first choice for the past 3 years. Of 29 evaluable cases, Heineke-Mikulicz method was used in 7 cases, and ileal patch method in 22 cases. An hourglass-like deformity was seen in 2 cases in the former method. Severely difficult catheterization, parastomal abscess, and acidosis occurred in one. Overall, 24 cases (83%) have come up with satisfactory results with minimal overflow incontinence in the early postoperative course. Although much longer followup is necessary, CUR's by Kock or Indiana pouch are more acceptable by bladder cancer patients requiring cystectomy.