達文西手術進行根除性膀胱及尿液分流術後腹內腸疝氣:案例報告

蔡禮賢、李瑋涓、陳冠亨、張兆祥

中國醫藥大學附設醫院 泌尿部

Li Hsien Tsai, Wei Jen Li, Cheng Guang Chen, Chao Hsiang Chang

Department of Urology, China Medical University Hospital, Taichung, Taiwan

  Radical cystectomy and urinary diversion have been seen as the most challenge procedure of urology field. The difficulty increased, even more, when the process was done by the laparoscopic or robotic method. We reported two cases of small bowel internal herniation caused by ureters strangulation after robotic-assisted radical cystectomy and urinary diversion. 

 

  Two patients received robotic radical cystectomy and urinary diversion. One patient received Indiana pouch, and another received ilea conduit. The patient’s history, oncological status, operation procedure, image and second operation record were reviewed and analyzed.

 

  The first patient was a 64-year-old female patient denied any significant medical history. She received robotic-assisted radical cystectomy and Indiana pouch for definitive treatment of bladder urothelial carcinoma. The Indiana pouch reconstruction was done extracorporeally with an 8cm incision from extended robotic trocar wound. Her second admission was due to urinary infection after bilateral DJ stent removal at postoperative day-38. Sudden onset of abdominal fullness, nausea with vomiting and constipation 20-day after the second admission. Abdominal CT showed obstruction ileus with distal intestine transitional zone and internal herniation between bilateral ureter. She received emergent explore laparotomy due to an internal hernia and possible small bowel strangulation. At laparotomy, bilateral ureters curvature and dilated small bowel were noted. Bilateral ureteroureterostomy sites were first identified then one segment of ileum herniation and adhesion between bilateral ureters was found. The herniated bowel loop was carefully dissected then manual reduction was done.

  The second patient was a male presented with an incidental finding of left hydronephrosis during postoperative image study. He received robotic-assisted radical cystectomy and ileal conduit for definitive treatment of bladder urothelial carcinoma. Abdominal CT 30-day after operation found left hydronephrosis and left distal ureter stricture. The stricture segment was around 4cm between peritoneal window beneath sigmoid colon and ureteroenteric anastomosis site. He denied any symptom and signed first. Recurrent left pyelonephritis during the observation period. The patient received open ureterolysis six months after the first operation. During the procedure, we found small bowel loop herniated from the space between bilateral ureters and conduit. The stricture ureter segment was surrounded by the herniated loop, and severe adhesion between ureter and intestine was found. Sufficient ureterolysis and reduction of herniation were done.

 

  Small bowel hernia obstruction result from internal herniation caused by ureter is extremely rare. To the best of knowledge, this is the first case report of small bowel obstruction and internal herniation between bilateral ureters after robotic radical cystectomy and Indiana pouch. There might be three reasons contributed to the rare complication. First, we used the right side robotic trocar as diversion stoma position instead of making another incision as the previous study mentioned. The tented pouch and ureters, therefore, acted as “hang rope” for the herniated segment. Second, to perform extracorporeal diversion, we dissected longer ureters than open method. The redundant ureters and pouch created a vast space of a potential hernia. Third, retroperitonealization was not performed during the operation. Regaining normal anatomy should decrease the incidence of an internal hernia.

  The presented case is the first case report of small bowel internal herniation and strangulation caused by bilateral ureters. Suitable stoma position, appropriate ureters dissected length and retroperitonealization can help preventing such catastrophic morbidity.