全腹腔鏡下子宮摘出術にて右尿管口が浮腫状に閉塞した1例-経腟的検体回収における尿路系損傷の可能性-

抄録

Introduction: Ureteral injury is a complication to be avoided in total laparoscopic hysterectomy (TLH), while occlusion of the ureteral orifice has not been reported yet.

Case: A 47-year-old nulliparous woman underwent surgery for a 10-cm-diameter uterine fibroid after pseudomenopause therapy. TLH was performed in accordance with the protocols after myomectomy. The urinary tract up to the ureteral tunnel was examined. The fibroid was divided into two and transvaginally collected. After the vaginal stump was occluded, a cystoscopy was performed. However, as the right ureteral orifice presented edema, the orifice and urine outflow could not be confirmed. Although drip infusion pyelography (DIP) was performed, the right renal pelvis was not visualized. Therefore, the right ureteral orifice was retracted with a Nelaton catheter to perform retrograde urography, and the right ureteral orifice was visualized without flexion or extension. On the basis of the above-mentioned findings, occlusion of the right ureteral orifice due to edema was diagnosed and treated with placement of a DJ ureteral catheter in the right ureteral orifice.

Discussion: Causes of the ureteral injury were verified from surgical records and images. The images confirmed that the practitioner's finger was strongly retracting near the right ureteral orifice at the time of transvaginal collection of a large specimen under the condition of severe extension of the vaginal wall. The possibility of this procedure to cause temporary edema in the right ureteral orifice, which leads to occlusion, was indicated. A specimen should be subdivided for a dynamically reasonable transvaginal collection in the future.

Results: In TLH, complications in the urinary system may occur not only during the perioperative procedure but also at the time of specimen collection. Therefore, cystoscopy with intravenous indigo carmine dye will be an important screening tool to ensure the safety of TLH.