福島医学雑誌 60 巻 3 号　2010

〔症例報告〕

尿管皮膚からのBCG灌流療法が有効であった上部尿路上皮内癌

羽賀　宣博¹⁾，日下部　崇²⁾，櫛田　信博³⁾

¹⁾会津中央病院　泌尿器科，²⁾同　病理部，³⁾福島県立医科大学　泌尿器科

（受付2010年4月1日　受理2010年6月18日）

Bacillus Calmette-guerin Therapy for in Situ Upper Urinary Tract CarcinomaUtilizing Cutaneous Ureterostomy

NOBUHIRO HAGA¹⁾, TAKASHI KUSAKABE²⁾ and NOBUHIRO KUSHIDA³⁾

¹⁾Department of Urology, Aizu Chuo Hospital, ²⁾Department of Pathology, Aizu Chuo Hospital, ³⁾Department of Urology, Fukushima Medical University

要旨: 75歳，男性。2008年9月，切迫性尿失禁を主訴に受診。顕微鏡的血尿を認め，尿細胞診では陽性であった。CT上，膀胱壁の壁肥厚を認めた。静脈性腎盂造影（IVP）上は，右尿管下端部に陰影欠損が疑われた。しかしながら，膀胱鏡上，右尿管口が同定できず尿管下端部の評価はできなかった。経尿道的膀胱腫瘍切除術（TURBT）を施行した。病理の結果は，尿路上皮癌（UC)，G3，pT1，前立腺部尿道にもUCが存在した。
　続いて，膀胱全摘除術，両側尿管皮膚術を施行した。病理組織学的診断は，腺癌G2>UC G3 pT4uN0M0，両側尿管断端は，術中迅速病理診断で陽性であった。両側尿管は断端陰性となるまで切除を追加した。
　術後第35病日から，右尿管皮膚からの尿流出が不良となった。尿細胞診では，腺癌が疑われたが，画像上は，右上部尿路に腫瘍性病変の存在は明らかではなかったため，上部尿路上皮内癌と診断した。右側に尿管ステントを挿入し，bacillus Calmette-Guerin （BCG） を逆行性に投与した。BCG投与後，臨床的なCRを得られ，カテーテル挿入なしでも，尿量が確保された。
　本症例のように，組織型がUCでなく腺癌の可能性がある上部尿路上皮内癌に対してもBCG 灌流療法が一つの治療選択肢になる可能性が示唆された。

索引用語: 上部尿路，上皮内癌，BCG 灌流療法

Abstract: A 75-year-old man presented with urge incontinence. Microscopic hematuria was detected and urinary cytology was positive. CT demonstrated the wall thickness of the urinary bladder. A filling defect was suspected in the right lower ureter on the intravenous pyelogram (IVP). We did not evaluate the right lower ureter because cystoscopy did not reveal the right ureteral orifice. Trans urethral resection of the bladder tumour (TURBT) was performed and high-grade urothelial carcinoma (UC, G3, pT1), which had infiltrated to the prostatic urethra was diagnosed.
Subsequently, radical cystectomy with bilateral ureterocutaneostomy was performed. Right nephroureterectomy was not performed simultaneously because carcinoma infiltration was found in the bilateral ureters during the operation and the general status was not favorable. Pathological findings showed grade 2, adenocarcinoma>grade 3, UC (pT4uN0M0).
Thirty-five days after the operation, urine volume from the right cutaneous ureterostomy decreased suddenly. Positive urinary cytology was obtained and adenocarcinoma was suspected. However, the presence of tumors from the right upper urinary tract was not detected by the radiographic studies. We diagnosed the right upper urinary tract carcinoma in situ (CIS) because adenocarcinoma was not confirmed pathologically. After insertion of the ureteral catheter, administration of bacillus Calmette-Guerin (BCG) was performed in a retrograde fashion. After BCG instillation, clinically complete response was achieved and the volume of urine improved following the right cutaneous ureterostomy without ureteral catheter insertion.
We suggest that BCG instillation from cutaneous ureterostomy is one of the effective therapeutic options for upper urinary tract CIS, which is highly likely to be adenocarcinoma.

Key words: carcinoma in situ, upper urinary tract, BCG therapy