半大腸切除術後併發輸尿管小腸瘻管之案例報告

黃裕賓1、黃子豪1,2、黃志賢1,2

台北榮民總醫院 泌尿部1；國立陽明交通大學醫學院 泌尿學科 書田泌尿科學研究中心2

Ureteroenteric Fistula after Hemicolectomy: A Case Report

Yu-Pin Huang1, Tzu-Hao Huang 1,2 , William J. Huang1,2

Department of Urology, Taipei Veterans General Hospital1

Department of Urology, School of Medicine and Shu-Tien Urological Institute,

National Yang Ming Chiao Tung University, Taipei, Taiwan2

Introduction:

A fistula is an abnormal communication between two epithelium-lined cavities. Causes of acquired fistulae include trauma, inflammation, radiation, and malignancy, and they can even be iatrogenic. Ureteroenteric fistulas are extremely rare. Patients with ureteroenteric fistulas may present with flank pain, hematuria, recurrent urinary tract infections, and diarrhea. Treatment included percutaneous nephrostomy and stent placement for urinary drainage with surgical repair. Here we report a case of ureteroenteric fistula after hemicolectomy in an elder woman.

Case report:

A 78-year-old woman who had hypertension and gastric ulcer under medication control and denied prior operation history before admitted for scheduled surgical intervention. Her previous colonoscopy revealed an annular tumor mass at ascending colon from anal verge 80cm, and the pathology of biopsy showed adenocarcinoma. She underwent laparoscopic right hemicolectomy subsequently.at our hospital. Right lower ureter was transected during the operation, thus laparoscopic right uretero-ureterostomy with double-J insertion was performed in the meantime. The final pathology showed adenocarcinoma of colon with pathologic T3 and N0 stage. A urinoma next to the ureter was noted on CT two weeks after surgery. We opted observation first since there was already a double-J stent and she was doing well clinically. She was discharged 30 days after surgery and double-J stent was removed 6 weeks after surgery. However, fever developed two months after discharge, she presented to our ER and CT revealed right hydronephrosis, progression of prior urinoma, and suspect abscess formation. We arranged a ureteroscopy on the next day. No anastomosis stricture was found, whereas contrast extravasation over right lower third ureter, along with contrast filling into small intestine lumen was noted on retrograde pyelography, which indicates the presence of a ureteroenteric fistula. Therefore, explore laparotomy was carried out on the next day. We found marked inflammatory change near previous anastomosis site with adhesion of colon and small intestine. Retrograde methylene blue injection from ureteroscope showed leakage over this inflammation site. Eventually, colorectal surgeons did a wedge resection of small bowel and fistula, and we did a psoas-hitch like maneuver, mobilizing the bladder, fixing it to the presacral tissue in order to separate the anastomosis leakage site from intestines. Instead of doing a ureteroneocystostomy, we decided to isolate the severely inflamed tissue, leaving it to heal spontaneously. We kept the double-J for 10 weeks postoperatively. Follow-up retrograde pyelography did not show extravasation of contrast, while proximal hydroureter was noted. Thus, we suggested long-term double-J indwelling for her and  she is now under regular outpatient follow-up, as well as double J replaced annually.

Conclusion:

Ureteroenteric fistulas are uncommon. For diagnosis, computed tomography is the modality of choice in working up urosepsis, and antegrade or retrograde ureterography is the most sensitive in the detection and characterization of a fistulous tract. Resection the bowel segment and stenting the ureter is the treatment of choice for functional kidney.

References:

1. Harcharan S. Gill. Surg Clin N Am 96 (2016) 583–592

2. Nam C. Yu, et al. Radiographics. Sep-Oct 2004;24(5):1331-52.