子宮内膜症性尿路疾患に対する腹腔鏡下手術―膀胱子宮内膜症，尿管子宮内膜症―

Laparoscopic surgery for endometriosis of the urinary tract : minimally invasive management for bladder endometriosis and ureteral endometriosis

　要旨：子宮内膜症は腹膜や卵巣のみならず広汎に分布しうる疾患である．ときに骨盤外など異所性に存在することもあり病変の分布やまたその癒着・線維化の程度は極めて多様である．近年，後腹膜深部に及ぶ子宮内膜症が注目されている．この中で稀な病態として尿管・膀胱など尿路系に及ぶ子宮内膜症がある．出血などの症状の他，狭窄や閉塞による腎機能障害を惹起する場合もある．治療として薬物療法だけでは限界があり，手術療法が重要な位置を占める．機器の進歩と手術技術の向上により，複雑な操作を要する手技も腹腔鏡下に行うことが可能となってきており，尿管周囲の深部に存在する内膜症病変，あるいは尿路自体の部分切除や再建などもより低侵襲に行うことができる．

　Endometriosis has the nature to spread extensively, not only on peritoneal superficial surface and ovarium, but may exist ectopically, and the distribution and the degree of adhesion and fibrosis varies from case to case. Recently endometriosis extending deeply into the retroperitoneal space has become the object of much attention. Although rare, there is a type of deeply infiltrating endometriosis involving the urinary tract, meaning the ureter and/or the bladder. This may cause urinary tract bleeding and/or renal dysfunction due to ureteral stenosis or obstruction. The role of surgical management is essential because the efficacy of medical treatment is limited. Development of the instrumentation and the surgical skills make it possible to perform very complicated procedures laparoscopically. As a result, it has became possible to manage deep endometriosis using minimally invasive surgery by removing the endometriotic lesion surrounding the ureter and/or performing segmental resection and reconstruction of the ureter