KURENAI : Kyoto University Research Information Repository Title DIVERTICULUM OF THE URETER, CASE REPORT Author(s) TOMOYOSHI, Tadao; KUZE, Masuji; SOFUE, Kiyoshi; NAGATANI, Yasuo Citation Issue Date URL 泌尿器科紀要 (1961), 7(11): 994-999 1961-11 http://hdl.handle.net/2433/112214 Right Type Textversion Departmental Bulletin Paper publisher Kyoto University 994 泌尿紀要7巻11号昭和36年11月 DIVERTICULUM OF THE Tadao URETER, CASE REPORT TOMOYOSHI and Masuji KUZE From the Department of Urology, Faculty of Medicine, Kyoto University, Kyoto, Japan (Director : Prof. T. Inada, M. D.) Kiyoshi SOFUE and Yasuo NAGATANI Flom the Department of Internal Medicine-2nd Division, Faculty of Medicine, Kyoto University, Kyoto, Japan (Director : Prof. T. Miyake, M. D.) INTRODUCTION Congenital diverticulum is one of the rarest fever. of the urological and a review of only 32 cases from National ureter March anomalies, literatures collects foreign and 7 from Japanese literatures. Here reported a case we recently experienced. is the female out-patient was first seen department of urology on January 12, 1960, being referred the medical ward and an episode fever. Her but otherwise January high history carcinoma. of fever noticed the no of Urinalysis and hematuria department had 1 after Physical no frequency, urination, examination 9, consultation She. had on normalities. pressure rigidity, on January a urological later. burning anywhere. D. of was no edema or Dec. 9, 1960, she gross medical 1961 and not of 39.5°C five days after period drinking beer and coffee, but it soon disappeared. She was hospitalized to was 20, 1960, she first developed the the diagnosis 1 plus Albumin RBC, but there blood pressure. was been to Himeji glomerulonephritis. She had never during under was said to show plus high hospitalized Hospital chronic 3 days attacks and had had 3 times of dilatation and curettage, ill. from of hematuria of recurrent family remarkable II-para because at was to April again CASE A 27-year-old She and no pain revealed no ab- P 76, R 17, T 36.5°C, blood 130/90. Abdomen was free of tenderness, distension or palpa- ble mass. Urinalysis showed & C. associated with chill and bilateral 1 plus, sugar lumbar Her power field, WBC 5-6 per high power field, a few epithelial cells, cast negative injected relief, vated pain. but her this time. first noted gross temperature was and again also In February hematuria. recurrent ele- treated gradually ture at this time continued 37.0°C with physician with a temporary to 39.0'C which with Streptomycin down family Streptomycin came 1960, she Tempera- to be around attacks of high negative, albumin and crystal negative. alkaligenes were terized urine. RBC 2-3 per high Pseudomonas cultured from Blood examination RBC 421 x 10', Flb. 83(V, color WBC 6200 with normal Bleeding time 18', capillary was showed index differential 4'30", resistance and cathe- clotting 0.98, count. time test 140 mm Hg T.TOMOYOSHIANDASSOCIATES-DIVERTICULUMOF↑HEURETER onbothsides. Sedimentationratewas normal. Bloodchemistry:Fastingbloodsugar wasthentransferredtoUrology strateabove,mentioneddiverticulum Retrogradestudywasrepeatedonly totalserumcholestero1130mg/dL,cho1- ontherightsidewithanattemptto esterolester94mg/d1.,Na143.2mEq/L., demonstratediverticulumbytakinga 118.OmEq/L,NPN18.7mg/dl.,Creati1血e O.7mg/dL. Renalclearancestudywascarriedout withresultsofeff.RPF758cc/min. placedat10cm.fromtheureteralori. 丘ce,however,thisalsofailedtogive u6apictureofdiverticulum. Thisfacttellsushowitisincidental todisclosesuchananomalyasureteral 14.7%(70.0%),andUF1.66cc/min.. diverticulum. (60')and84%(120').Fishberg'scon. centrationtestwasalsonorma1. Liverfunctiontestswereasfollows= icterusindex5,serumbilirubinO.8mg/ Explorationoftherightureterwas carriedouton27February.Withthe patientplacedinthesupineposition, withtherightsidealittleelevated,a pararectusincisiollwasmadeextellding d1.,thymolturbidity3-4u.,zincturbi- fromtheleveloftheumbilicustothe dity12u.. leveloftheanteriorsuperioriliacangle. Cystoscopyandretrogradepyelogra- Theincisionwasdeepenedintheusual phywasfirstperformedon12January. manner,thentheperitoneumwasre- Bladdeゴwasgrosslynormalexceptfor tractedmedially.Theureterwasfound somewhatedematousvesicalneckand tobepartlyduplicatedinsuchaway afewspottedcy忌tsintrigone.Both asrunninginpararellwithinthecom- ureterswerecatheterizedupto20cm. monureteralsheath.Themid・portion withoutmeetinganyobstructio11.In・ oftheureterwasmobilizedtosee digocarminetestshOwed6xcellentexcre・ anatomicalsituationexactly.0且eofthe tionwithin5minutes. twoureteralstructureswasnotedto KUBwasnorma1.Retrogradepyelo- . pyelogramwithaureteralcathter (143%),eff.RBF1149cc/min.(101%),FF PSPtestwas44%(15'),65%(30'),77% . Excretorypyelogramfailedtodenlon. 63mg/d1・,totalserumprotein7.09/dl。, K4.25mEq/L.,Ca4.66mEq/L.,andCl 995 haveablindendwherenorudimentry gram(Fig.1.)demollstratednormal kidneywasrecognized.Atraction lookingpye1Gcalycealsystemonboth suturewasplacedonthetipofthe sideswithnodilatationintheupper diverticulumwhichwasbluntlyfreed urlnarytract.Inthemid-ureteronthe downtotheleveloftheiliacvessels right,therewasanunusualstructure whereitconjoirledtotheoriginalureter extendingupwardsjustlaterallytothe withnormalcaliberofcommunicating ureter.Aureteralcatheterwasseen lumen.Thediverticulumwasamputated inthispouch.likestructuretheoutline fromtheureter,andtheopeningwas ofwhichwaswelldelineatedonthe primarilyclosedwiththreeinterrupted film.Extravasationcouldbeeasilyruled suturesQfOOOcatgut.Postoperatively, outandadiagnosiswasmadeasdiver- thepatientdidwellandleftthehospi・ ticulumoftherightureter.Thepatient talintwoweeks. ダ 996 T.ToMoYosHIANDASSOCIATES-DIVERTICULUMOFTHEURETER thebladder. Removed・specimenwasaureter・100kingstructureof10cm.10ngwithnormal Areviewoflite'raturespresentsus caliber。Completelumenwasrecognized 40casesofcongenitaldiverticu1ロmof throughtheentirelength.Notumor theureter32beingforeignand8dome・ orhemorrhagewasseeninsidethe stic.Theycanbetabulatedasfollows. diverticulum(Fig.2). TabIe1. 40casesofcongenitaldiverti噂 Histologically,thewa1正ofdiverticulum culumoftheureter complizestransitionalepithelium,com- Foreign (32) pletethreelayersofsmoothmusqle andperiureteralsheathofconnective Domestic (8) Male 11 3 Female 21 5 Right 14 7 Left 17 1 1 0 Sex tissue.Thereisslightlymphocytic infiltrationinthesubmucosaassociated withmildinflammatoryproliferatiollof Side themucosalepithelium(Fig.3). Bilatera1 IVPtakenonthe8thpostoperative dayshowedsatisfactoryexcretiona且d Blind。ending 20 bifidureter drainagewithoutanyevidenceofhydro・ Globular sac nephrosisorextravasation. DISCUSSlON Siteof Diverti. culum Diverticulumoftheuretermightbe convenientlyclassifiedasfollows. A.Collgenital(true)diverticulum 4 ' Type UPjunctiQn toupper ureter Mid.ureter tosacroiliac joint 12 4 9 1 14 5 9 2 Juxtavesical 1。Typeofblind・e且dingbifidureter Ourcaseisalsoinc韮uded. 2.Typeofglobularsac B.Acquired(false)diverticulum Of40casesreportedsofar,de負 1.Typeofmultiplediverticulosis 且ite diagnosiswasmadepreoperativelyin28 byretrogradepyelographyand4byIVP. 2.Typeofglobularsac Sevencaseswereincidentallyfoundat BothA.1.andA.2.arethoughtto operation.Theirtreatmentsconsistof beofthesameembryologicorigin.It ・17diverticulectomy,10nephrectomy isbelievedthatoneofthedividedure・ f teralstalksceasestodevelopin3to4 nosurgery,1ureteraldilatation,1re- weeksoffetallifeandgivesriseto movalofstone,1implantationofthe suchastructureasdiverticulum. ureterand3unknown. B.1.isofteni11且ammatoryinnature, Hereisshownatableof8casesof truediverticulumoftheureterreported whereasB.2.isduetotraumaorstric・ ture.Di丘erentialdiagnosisshouldbe strictlymadeinregardtosimilarcondi・ tionsoftheureteraspartialhydroure。 ter,ureterocele,blind・endingureter inJapaneseliteratures(Table2). COハ1C五ころSION Diverticulumoftheureterisacondi- openinginthebladder,andacommuni・ tionnotsoextremelyrarebutseldom cationofureterwithdiverticulumof disclosedbecausethepatientwithdi一 ,7 T・TOMoYos田ANDASSOCIATES-DIVERTICULUMOFTHEURETER 997 Table2.CongenitaldiverticulumoftheureterreportedinJapan (。諮守翻蹄観難。= 1瀞h'M39R窺 ,・・一購 Takahashi 2TsuchiyaM18RL5-L1 1936 Iwashita 3etal. 1940 15 M37RL4L2 Tada 4Shintani 1955 LowerF32R 7cm. F50Rfrom 2.2×1.0 U.0. 1958 F57R ,3{・fl1?…hiF、,R・ 1961artery Conservative Jap.J. Derm.& Urol. 29=711,1929 Eunuchoid IVP Conservative Jap.J.of Uro1. 25:614,1936 Pyelitis Cystitis RP Conservative Jap.」.of Urol, 29:210,1940 OperatiOn Pain CIQudy urine RP Paininloin Intermit.RP tent hematuria 藍waM62L盤1H・n.eg, Takai 7Horiyone 1960 RP Urinary stasis Ureter3.5×1.5 Momose 5eta1. 1957 ・鱗 6∼7 ・・ver L5 膳 O.3×0.8 ・h・1。.。 Painin lOwer abdomen RP Hematuria RP Unknown ActaUrol. 1:271,1955 Nephroureterectomy Derm.et Uro1.(Japan) 11:1079,1957 PartialUreterectomywith reimplantation intobladder Jap.J.of Urol. 49:388,1958 1馬竪誰塁器鑑一Jap.J.of UroL ty(End.to.end anastomosis) Diverticu王ec. tomy 51:825,1960 Thisarticle verticulummaybeasymptomaticunless extendingupwardjustleaterallytothe thereisassociatedurinarytractinfec- ureterinpararellwithit. tion.Moreover,aroutineurological (ThispaperwasreadatthcthirtcenthUro. examinationmightfrequentlyfailto 10gicalMeetingofKanswaiDistrict,Japanon demollstratediverticulumasweexperi- June25,'61byoneofthcauthors,Dr.Tomo- enced.Diverticulumoftenfacilitates yoshi.) urinarytractinfectioncausingurinary REFfr"1∼ 五'ノ>CES stasisand/orextrinsicpressureonthe ureter.Diverticulectomy choiceoftreatmentwith 1susuallya ureteroplasty 1)Bugbee,H.G,J.Uro1り26:215,1931。 2)1(retschmer,H.L:J.Urol.,30=61,1933. 3)Davis,R.L:J.Urol.,31473,1934. ifnecessary. 4)Gantham,L,W.:J.Uro1.,45832,1941. sσMMARY 5)Richardson,E.J.;J.Uro1.,47・535,1942. 6)Dodson,A.1.:J.UroL,52526,1944. Diverticulumoftherightureterwas 7)Hanley,H.G.;Brit.J.IJroL17:50,1945. foundina27-year-oldfemalewithre・ currentpyelonephritisprobabledueto thepresenceofdiverticulum,whichwas 8)Culp,0.S.J,UroL,58309,1947. 9)Pratt,J.G,Gahagan,H.Q.andFisch. man,J.L.」.Uro1.,58322,1947. surgicallyremovedand10cm.inlength 10)Mayers,M.M.:J.Urolり61344,1949. beingthetypeofblind-endingureter 11)McGraw,A.B.andCulp,0.S_J.Uro1., arisingatthelevelofiliacvesselsand 67262,1952. 998 T.TOMOYOSH【ANDASS㏄IATES-DIVERTICULUMOFTHEURErER 28)Brachmann,W.:Zschr.UroL,52.56, 12)Davis,W.E.andGarvey,F.K.:J.UroL, 1959. 69:621,1953. 29)Gaga,A.Urol.int.,10179,1960. 13)Bowie,C.W.,Garvey,F.K.,Boyce,W. H.andPautler,E.E.J.Urol.,71:293, 30)高橋・三好:皮泌誌,29:711,1929. 1954. 31)高橋・土屋:体性,23:485,1936. 14)Hillenbrand,H.J..J.Uro1.,48:488,1955, 32)高橋・土屋=日泌尿会誌,25:614,1936. 15)Mims,M.M.:J.UroL,84.297,1960. 33)高橋・土屋:皮泌誌,43:589,1938. 16)Rank,W.B.,Mellinger,GT.andSpiro, 34)岩下・谷野・中内:体 35)岩下・谷野・中内:日 E.:J.Urol.,83=566,1960. 性,26:633,1939. 泌尿会誌,29:210, 1940. 17)Dolan,P.A.andKirkpatrick,W.E:J. Urol.,83:570,1960. 36)三矢・橋爪・相馬 18)Janke,Z.Zschr.Urol.,19441,1925. 37)三矢・橋爪・相馬:臨 19)Minder,J.:Zschr.Urol.,19680,1925. 38)田中:日 20)Janke,Z.Zschr.Uro1。,20347,1926. 39)赤坂他:日 21)GottliebZschr,Urol.,21:524,1927. 40)多田・新谷:泌 22)Vormann,B.:Zschr.Urol.,23:124,1929. 41)百瀬・小林・吉田:臨 23)Chwalla,R.:Zschr.Urol.,24641,1930. 42)百瀬・小林・吉田:日 24)Kaiser,E.undHascheck,H.:Zschr.Urol., ・日泌尿会誌,40:50,1949. 床皮泌,5:166,1951. 外科誌,54:87,1953. 泌尿会誌,45:103,1954. 尿紀要,1:271,1955. 床皮泌,11:1079,1957. 泌尿会誌,49:268, 1958. 46:748,1953, 25)Jaki,J.undFarkas,L.:Zschr.Urol,,47・ 316,1954. 43)金沢・瀬川:日 44)高井・堀米=日 45)土屋文雄:日泌尿会誌,49:388,1958. 泌尿会誌,51:825,1960. 本泌尿器科全書,2皿:708∼730, 1961. 26)Bacher,E.:Zschr,Urol.,51326,1958. 46)Campbe11:Urology,VoL1363,1954. 27)Haschak,H.undSchimatzek,A.:Zschr. Uro1.,51:422,1958. 》, 二滋磁、」 ○ '■%「惣・.「・幽∼. 樹 4 Fig.LRetrogradepyelogram.Diverti- Fig.2.Grossspecimenofremoved culumoftherightureterisdemon- diverticulum.Itstipisontheleft stratedasapouchformationlaterally side. totheureter, T. ;:'.• .., TOMOYOSHI A • .• AND •, ASSOCIATES-DIVERTICULUM , Cd.17; r"- 4ti• 4,-.3, 2i•.' .. . :.,' •j'';` ' • ' ^ - •:, ., ,......,: • .-...i.. , ,,,,.tsot _-,, 1 • ' ,'!••'k •: •';:!- • 4 A . . . 1•, ','..1 ..... v,.. ',,-;,-1 /PC Fig. 3. Photomicrogram 憩 *4...,4.1.1 . .. .- ,...f., '- -,,..•.- ,,•,.. ,..17.,, „.,..,,,1:7• :.."":- ': , -, i 00 ry IN... , . ••.t ., -..:;!,_,,,,.:,;4>..," ZAtft 4 li, _ of the wall of diverticulum. Fig. 3. (A) Transitional cell epithelium and inner longitudinal layer of the smooth muscle. Slight lymphocytic infiltration in the submucosa with mild epithelial proliferation. 管 999 .'v‘••;I;:k,;,4T, NI, 尿 . URETER 'g'::'i)irs .le. ,,.'..,'.•1'...:.,,-( ,...,..•..,... 1.2,.*., ;'.'.;^•,,,!3, '.t . ; tI.,• •....:^:",•.•l'..s .•''"1'''7i!,,,,,V.•` .1,.,,•'.1.'•..5,x..1,lit:- .fi,..:‘.,•,:.r :„ ,-;..,•.,o.,,,". , ,. \., THE '1 ' v-:,k1,,..... 106'f A 1\ :.t.7Or ' N 4 4Ur•...'C.:(':etC.ti.•'.'11- -:"),' '',.• . ' ' •'It,.C:',r•• 1 4.1 ••:`:•°, OF Fig. 3. (B) Median circular longitudinal muscular layer. is very thin. 室 and outer The latter の1例京都大学医学部泌尿器科教室(主任稲田務教授) 友吉唯夫久世益治京都大学医学部内科第2講座(主任三宅儀教授) 祖父江鮮長谷泰夫先天性(真性)尿管憩室は極めて稀に接する泌尿器科的先天異常のひとつであつて,現在の縦の筋層構た.本邦報告例中,長症例を含む)を集計しうるにすぎない.我々の症 cmに次ぐ2番例は腎盂腎炎にもとつくと思われる血尿を主訴型尿管憩室に対するものとしては最初の憩室摘とせる27才の女子患者に於て,逆除報告例である. 行性ピエログ然にも尿管カテーテルが尿管憩室内に入り,発見し得たもので,手術により, 腸骨動脈交叉部直上より分岐して本来の尿管のさに於て高橋目のものであり,重土屋の15 複尿管盲管 (稿を終えるに当り,御指導と御校閲をたまわつた恩師稲田教授及び三宅教授に心から感謝致します). 本論文の要旨は1961年6月25日,大阪における第外側をこれと平行して上向する重複尿管盲管型 13回日本泌尿器科学会関西地方会の席上で著者の一の尿管憩室を摘除した.標本は長さ10.Ocm,太人友吉が口演発表した. さは正常尿管大で,全長に亘つて管腔を有し, x 輪,外造と移行上皮を有し軽度の憩室炎を伴なつていところ外国文献より32例,本邦文献より8例(本ラムを行い,偶 - 組織学的にも完全な内縦,中