膀胱拡大術の臨床研究

(その3) ノベクタン (液体合成樹脂) 噴霧の薄紙を用いた膀胱拡大術の膀胱腫瘍に対する研究 (1)

抄録

We previously reported in “A Study on Cystoplasty by Regeneration of Contracted Bladder Using Novectane (Liquid Synthetic Resin)-sprayed Thin Paper (1) and (2)” that we had conducted cystoplasty by regeneration in various cases of contracted bladder Among these cases there was a case in which the bladder capacity increased from 20cc to 400cc.
The period of observation after operation on these cases was from 18-30 months. Favorable results have been maintained in all the cases.
In this paper we report on a case in which this method of cystoplasty was applied to tumor of bladder. Case 1 was a 40-year-old male. For about 3 months macroscopic hematuria was present without subjective symptoms. Clinical observations by cystogram in prone position revealed a large filling defect as shown in Fig. 1 by the arrow.
The cystoscopy revealed a large tumor surrounding the vertux of the bladder. The operation was performed under the spinal anesthesia.
As shown in Fig. 2, we excised 4/5-5/6 of the bladder together with a part of the peritoneum, leaving the neck of the bladder, the trigone of the bladder and the ureteral orifices on both sides. As shown in Fig. 2, the ureteral catheters were inserted from the ureteral of ifices on both sides. This ureteral catheter was removed immediately after excision of the bladder. Then a porous Nelaton catheter No. 15 was inserted into the bladder transurethrally. This method of cystoplasty is the same as that used for cystoplasty of Contracted Bladder. The prepared Novectane sprayed thin paper bladder was sutured to the residual bladder by interrupted sutures using 00 cutgut as shown in Fig. 4. The peritonuem was sutured by interrupted No. 4 silk sutures. We placed the drain on both sides of the artificial bladder and finished this operation by suturing the fascia and skin.
The excised bladder is shown in Fig. 3. The arrow indicates the tumor. The microscopic pathological findings showed that there was a third grade transitional cell carcinoma. The operation time was about 2 hours. We continued the extraction of urine by Nelaton catheter by an aspirator for about 5 days. After 7 days we removed all the sutures and replaced the Nelaton catheter with a bag catheter. Then the patient was allowed to walk. After about 3 weeks the artificial bladder fell off from the regenerated granulation bladder wall. After we had extracted the artificial bladder transurethrally, we made the patient urinate by himself.
Clinical observations by cystogram are given in Figs. 5, (1), (2), (3), and (4). An almost normal cystogram pattern was observed after a month in this case. The residual urine was about 40cc. The cystograms revealed a remarkably increased capacity with the lapse of time. But after a month the cystogram showed a Vesico-Ureteral reflux. This reflux is observed in the cystogram even after a year.
This was an instructive and difficult case, since all the 15 pieces of No. 4 silk suture used for suturing the peritoneum appeared in the bladder and remained as foreign materials as shown by the arrow in Fig. 6. Therefore we extracted all the silk sutures transurethrally. In this method of cystoplasty the cutgut should be used, even for suturing the peritoneum. The entire bladder wall was covered with normal regenerated mucous membrane after 5 months as shown in Fig. 7.
Natural urination at one time was 350-400cc, 15 months after cystoplasty. Residual urine was less than 30cc. The volume of liquid at maximum desire to urinate was 270cc when the inner pressure of the bladder was 21-30mmHg, 5 months after the cystoplasty. The volume of liquid at maximum desire to urinate was 290cc when the inner pressure of the bladder was 40mmHg 12 months after the cystoplasty.
Urine analysis in this case revealed protein +-±, sediment white cell +-±, red cell +, and bacteria-
This patient was treated neither by chemotherapy nor by the radiation thera