経腟的尿道憩室切除術および尿道腟瘻閉鎖術における手術体位の工夫  [in Japanese] AN OPERATIVE POSITION SUITABLE FOR TRANSVAGINAL EXCISION OF URETHRAL DIVERTICULUM OR CLOSURE OF URETHROVAGINAL FISTULA  [in Japanese]

女性の経腟的尿道憩室切除術は,尿道腟瘻などの合併症の頻度も高く,泌尿器科の手術の中で繊細な操作を必要とする比較的難易度の高い手術の1つである.われわれは,砕石位で経腟的尿道憩室切除術を施行したが,術後尿道腟瘻が発生し,その後砕石位で瘻孔閉鎖術を施行するも治癒せず,体位を腹臥位開脚膝位とすることで再度瘻孔閉鎖術を施行したところ成功した症例を経験した.腹臥位開脚膝位は砕石位と比較して,(1)術野が明るく,広く,見やすいので,尿道全周や膀胱頸部近傍の操作でも死角がなく,(2)剥離や運針操作が安全かつ正確に行え,(3)後腟壁をリトラクターで固定すれば,助手も術者と同じ視野で両手が使える,などの利点がある.経腟的尿道憩室切除術や尿道腟瘻閉鎖術に際しては,腹臥位開脚膝位が良好な術野を提供し,術者の疲労度も小さく,安全かつ確実な手術操作が行える.

Among the various surgeries in female urology, transvaginal excision of urethral diverticulum needs careful and meticulous procedures in order to avoid some operative complications, such as urethral stricture or urethrovaginal fistula. In the present report, we present a woman with urethral diverticulum who initially underwent transvaginal excision of diverticulum in the dorsal lithotomy position, but she was complicated with urethrovaginal fistula postoperatively. Unfortunately, we failed to repair her fistula when she underwent excision of the fistula in the dorsal lithotomy position. With reconsideration of an operative position useful for transvaginal surgery, we succeeded in fistula closure in the Jackknife prone reverse-lithotomy position, and thereafter, two subsequent patients with urethral diverticulum were successfully treated with transvaginal excision of diverticulum in this operative position. In the transvaginal approach to the peri-urethral disorders, the Jackknife prone reverse-lithotomy position was notably superior to the dorsal lithotomy position with the following advantages: 1) the surgeons can easily operate in a bright and large surgical site without any blind view. 2) the surgeons can dissect and suture safely and accurately. 3) the assistants also can help in the operation bimanually in the same view as the surgeon when the posterior vaginal wall is fixed with a retractor.