膀胱子宮瘻に対して膀胱鏡を併用し腹腔鏡下修復術を施行した1例

Laparoscopic repair for vesicouterine fistula using cystoscope

◆要旨：患者は40歳，女性．4回の開腹術歴（子宮筋腫核出術2回，帝王切開術2回）があり，2回目の帝王切開術時に膀胱を損傷し，膀胱子宮瘻となった．腟性尿失禁のほか，月経時血尿と慢性骨盤痛を主訴に，発症1年後に当院紹介となった．膀胱鏡および膀胱内色素注入検査で膀胱子宮瘻と診断し，腹腔鏡下子宮全摘出術および膀胱瘻修復術を施行した．瘻孔部分の子宮筋層を膀胱壁に残すように切開し，いったん子宮を摘出したのちに膀胱鏡を併用しながら瘻孔部から残存子宮筋層と膀胱筋層を除去後，瘻孔を閉鎖した．術後より骨盤痛は消失し，術後1年6か月経過したが瘻孔の再発も認めていない．膀胱子宮瘻症例にも，手技の工夫により，腹腔鏡下手術が可能である．

Vesicouterine fistula （VUF） is a rare complication of cesarean section. We successfully managed to repair VUF by laparoscopic surgery and cystoscope. A 40-year-old woman with a history of four prior laparotomies, two myomectomies, and two cesarean sections, developed a VUF following the second cesarean section. After undergoing therapy for one year, she was admitted to our hospital with the chief complaints of continuous urinary incontinence, cyclic hematuria, and chronic pelvic pain. Cystoscopy demonstrated a fistula and an indigo carmine test showed leakage of urine from the uterine cervix. Pelvic magnetic resonance imaging showed a large uterine myoma. Based on the clinical picture and her symptoms, a decision was made to schedule a total laparoscopic hysterectomy and fistula repair after starting gonadotropin-releasing hormone agonist treatment for four months. The laparoscopic hysterectomy started with identification of the pathological connection between the uterus and the bladder. Subsequently, the rest of the uterus was resected off the bladder and was removed using the laparoscope and cystoscope, and the fistula was closed by the urologists. The operation time was 385 minutes and the blood loss was 400ml. At 18 months following surgery, there is no recurrence of VUF and no pelvic pain. Laparoscopic repair for VUF using cystoscope appears to be safe and feasible.