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1 대한내과학회지 : 제 76 권부록 1 호 2009 복막뒤콩팥요관절제술후성공적인복막투석재개 1예 한양대학교의과대학 1 내과학교실, 2 비뇨기과학교실 박동원 1 김원준 1 박준성 1 이창화 1 김근호 1 우영남 2 강종명 1 Successful reinstitution of peritoneal dialysis after retroperitoneal nephroureterectomy Dong Won Park, M.D. 1, Won Jun Kim, M.D. 1, Joon-Sung Park, M.D. 1, Chang Hwa Lee, M.D. 1, Gheun-Ho Kim, M.D. 1, Young Nam Woo, M.D. 2 and Chong Myung Kang, M.D. 1 Departments of 1 Internal Medicine and 2 Urology, Hanyang University College of Medicine, Seoul, Korea Peritoneal dialysis is an important therapeutic option for patients with end-stage renal disease, and the peritoneal membrane is the lifeline for peritoneal dialysis patients. Therefore, strategies to maintain the health of the peritoneal membrane are very important. A 64-year-old female who had been undergoing continuous ambulatory peritoneal dialysis (CAPD) for the past 6 years was admitted because of painless gross hematuria. On abdominal computed tomography (CT), a mass was found in her left renal pelvis. A nephroureterectomy was performed via a retroperitoneal approach without any complications. Peritoneal dialysis was resumed 4 hours later. We report peritoneum-preserving nephroureterectomy via a retroperitoneal approach in a patient on CAPD. (Korean J Med 76:S135-S139, 2009) Key Words: Reinstitution; Peritoneal dialysis; Urothelial cell carcinoma; Retroperitoneal; Nephroureterectomy 서론복막은일반적으로인체의내장을보호하는인체의숙주방어역할을수행하며, 복막투석환자에서혈액과복막투석액사이의용질수송과초미세여과를이용하여수분, 염분, 독소및여러산화물들을제거하는중요한역할을한다 1,2). 그러나이러한복막은환자의기저질환, 복막투석액의종류 및감염, 탈장과같은복막투석의합병증에의해방해를받게된다. 복막투석과관련한합병증으로인한외과적수술이필요한경우에서는혈액투석으로전환이필요하기도하며, 이로인해복막투석의실패를가져오기도한다 3-5). 특히복막투석환자에서수술적치료가필요한경우에복막손상을최소화하기위한노력이필요하지만, 복막투석환자가복부수술을받을경우복막손상을줄이며복막을유 Received: Accepted: Correspondence to Chong Myung Kang, M.D., Ph.D., Department of Internal Medicine, Hanyang University College of Medicine, 17 Haengdang-dong, Seongdong-gu, Seoul , Korea kangjm@hanyang.ac.kr - S 135 -

- The Korean Journal of Medicine: Vol. 76, Suppl. 1, 2009 - Figure 1. At cystoscopy, bloody urine was seen flowing from the left ureteral orifice (arrow). Figure 2.

저자들은복막투석환자 1예에서신우요로상피세포암을진단하고, 그치료를위하여복막뒤접근법으로콩팥요관절제술시행하였다. 그결과복막기능을유지하면서복막투석재개가가능하였기에문헌고찰과함께보고하는바이다. 증례환자 : 권, 여자 64세주소 : 통증없는육안적혈뇨현병력 : 15년전부터류마티스관절염으로치료받다가만성세관간질질환이발생하였다.

2 - The Korean Journal of Medicine: Vol. 76, Suppl. 1, Figure 1. At cystoscopy, bloody urine was seen flowing from the left ureteral orifice (arrow). Figure 2. Abdominal CT showed a nodular lesion in the left renal pelvis (arrow), with neither lymphadenopathy nor fatty infiltration seen around the tumor. 지하기위한지침은아직까지분명하게알려지지않았다 6). 저자들은복막투석환자 1예에서신우요로상피세포암을진단하고, 그치료를위하여복막뒤접근법으로콩팥요관절제술시행하였다. 그결과복막기능을유지하면서복막투석재개가가능하였기에문헌고찰과함께보고하는바이다. 증례환자 : 권, 여자 64세주소 : 통증없는육안적혈뇨현병력 : 15년전부터류마티스관절염으로치료받다가만성세관간질질환이발생하였다. 질소혈증이점차진행하여 6 년전부터지속적외래복막투석을시작하였다. 내원하기 1 달전부터통증없는육안적혈뇨가발생하여입원하였다. 요중에는간헐적으로피떡이배출되었으나, 빈뇨, 주저뇨및요통은호소하지않았고, 발열, 오한및체중감소또한없었다. 과거력 : 2년전에당뇨병을진단받고개인의원에서경구혈당강하제를복용중이었다. 1년전에고혈압을발견하여안지오텐신전환효소억제제를투여하고있었다. 가족력 : 특이사항없었다. 사회력 : 흡연과음주력은없었다. 진찰소견 : 혈압 150/90 mmhg, 체온 36.1, 맥박 88회 / 분, 호흡 20회 / 분이었다. 결막은창백하지않았고, 흉부진찰에서특이소견없었다. 복부는부드럽지만팽만되어있었다. 장음 은정상적이었고, 복부에압통이나반발통은없었으며종괴는촉지되지않았다. 늑골척추각압통과함요부종은없었다. 검사소견 : 일반혈액검사에서백혈구 5,400/mm 3, 혈색소 11.8 g/dl, 헤마토크리트 38.0%, 혈소판 212,000/mm 3 이었고, 전해질은 Na meq/l, K meq/l, Cl meq/l, - HCO meq/l이었다. 심전도는동성빈맥소견이었다. 혈액화학검사에서혈중요소질소 48 mg/dl, 크레아티닌 8.4 mg/dl, 콜레스테롤 246 mg/dl, 총단백 7.3 g/dl, 알부민 4.1 g/dl, 칼슘 9.4 mg/dl, 인 5.4 mg/dl, 총빌리루빈 0.2 mg/dl, AST 20 IU/L, ALT 27 IU/L, 알칼리포스파타제 80 IU/L 였다. 혈액응고검사에서프로트롬빈시간 (INR) 1.10, 활성화부분트롬보플라스틴시간 32초였다. 요검사는맑은황색, 비중 1.015, 알부민 2+, 잠혈 2+, nitrite 음성, WBC 0-1/HPF, RBC 20-29/HPF였다. 요세포진검사에서악성세포는발견되지않았다. 방광경검사에서좌측요관구멍으로부터육안적혈뇨가관찰되어좌측콩팥의출혈을시사하였으나, 방광내부에종괴, 출혈및벽면의잔기둥형성소견은관찰되지않았다 ( 그림 1). 복부전산화단층촬영에서양측신장은위축되어있었고, 좌측신우내에조영이증가된직경 0.5 cm의종괴가관찰되었으나, 주변의림프절병증이나지방침윤소견은없었다 ( 그림 2). 치료및임상경과 : 좌측신우의악성종양으로임상진단하고, 수술을위해비뇨기과로전과하였다. 복막뒤접근법으 - S 136 -

The tumor consisted of atypical urothelial cells with papillary growth (A, H&E stain, 100).

3 - Dong Won Park, et al. Successful reinstitution of peritoneal dialysis after retroperitoneal nephroureterectomy - A Figure 3. Microscopically, the left pelvis revealed papillary urothelial carcinoma, confined to the subepithelial connective tissue without invasion of the renal parenchyma. The tumor consisted of atypical urothelial cells with papillary growth (A, H&E stain, 100). The papillary architecture was well preserved and showed a moderate degree of nuclear pleomorphism (B, H&E stain, 400). B 로좌측콩팥요관절제술을시행받았으며그과정은다음과같다. 환자를우측측와위로눕히고좌측 12번째늑골위에서배꼽직상방으로 15 cm 피부절개후배바깥빗근 (obliquus externus abdominis), 배속빗근 (obliquus internus abdominis), 배가로근 (transversus abdominis muscle), 배가로근막 (transversalis fascia) 순으로열어복막을내측으로이동시키고복막뒤공간을연후신장을둘러싼제로타근막 (Gerota s fascia) 을확인하였다. 좌측신장은 cm으로위축되어있었고, 주변과유착은없었다. 콩팥요관절제술시행후, 수술중손상된복막을보강하였다. 복막뒤공간내에출혈이없음을확인하고배액관을유치한후수술을마쳤다. 적출신에서신우종양은신실질을침범하지않은고등급유두상요로상피세포암종 (papillary uroepithelial carcinoma, high grade) 으로조직학적진단하였고 ( 그림 3), 병기는 T1N0M0 stage I이었다. 환자는수술후 4시간지나서복막투석을재개하였고, 이후현재까지합병증없이 1일 4회의정규적인복막투석을성공적으로수행하고있다. 고찰현재많은말기신질환환자가이용하는복막투석은혈액투석에비해시간활용이더자유로우며, 혈역학적안정이필요한심부전및협심증환자와혈관질환이있는경우에더선호되는신대체요법이다 7). 그러나복막은다양한요인에의해그생리적기능을발휘할수없게된다. 당뇨병등의 기저질환, 복막투석액에포함된고농도의당과그에따른당분해산물, 생체부적합완충제, 잦은복막염등은복막의섬유화와혈관경화를포함한복막의변화를초래하여복막의기능을저하시킨다. 복막투석과관련하여발생할수있는탈장, 도관의이동, 엉킴, 그물막쌈등의합병증은치료를위해외과적수술이필요하므로결국복막손상을유발하게된다 3-5). 복막투석환자에서외과적응급상황이나종양이발생한다면외과적수술이필요하게되어복막을손상시킬수있다 6). 후천성낭성콩팥병과콩팥세포암은혈액투석을하는말기신질환환자에서유병률이증가하는것으로알려져있다 8,9). 한연구에서는지속적외래복막투석환자에서도혈액투석환자와비교하여후천성낭성콩팥병의유병률에차이가없었고 (41.1% vs. 47.1%), 콩팥세포암도발생하였다 (0.4% vs. 1.5%) 10). 본증례에서진단된요로상피세포암은일반인과비교하여혈액투석환자에서유병률이높으며 11), 현재일반적으로유병률이증가하는추세에있다 12). 이러한비뇨기계암은수술적치료가반드시필요하므로수술에따른복막손상을줄이기위한노력이요구된다. 상부요로비뇨기계에서발생하는요로상피세포암은전체요로상피세포암의 5% 내외를차지하는아직까지비교적드문암이지만 13), 37~52.3% 에서고등급의분화를보이며 43~ 61% 에서 T2 이상의 stage를보이는비교적공격적인암이다 14,15). 따라서현재상부요로비뇨기계에서발생하는요로상피세포암은방광주위박리를포함한개방콩팥요관절제술 - S 137 -

4 - 대한내과학회지 : 제 76 권부록 1 호 이표준치료로알려져있다. 이러한개방콩팥요관절제술은일반적으로복막뒤접근법 (retroperitoneal approach) 을통해시행된다 12). 최근전통적인개방콩팥요관절제술에비해실혈의위험이적고회복기간을단축시킬수있는복강경을이용한콩팥요관절제술이임상에도입되고있다 16). 그러나복강경콩팥요관절제술은일반적으로시행되고있는개방콩팥요관절제술에비해수술시간을줄이지못하고대상자선정에있어암크기의제한을받게되며수술공간이작아종양을충분히제거하기어렵다. 또한도입부재발이발생할수있고방광및국소재발을줄이지못한다는보고가있으므로 16,17), 본증례에서는복막손상을피하고요로상피세포암의근치를위해복막뒤접근법으로개방콩팥요관절제술을시행하였다. 복막투석환자에서복막손상을줄이기위해복막뒤접근법을이용한복부수술이현재까지다양하게시도된바있다. 복막투석중인 2명의환자에서복막뒤접근법을통한대동맥동맥류복원술시행후 36시간만에복막투석을재개한예가보고되었다 18). 경복막접근법과비교할때, 복막뒤접근법은대동맥수술중실혈의위험이적고정질액요구량이적었으며합병증발생을낮추고재원일수를감소시키는장점이있었다 19,20). 본증례에서는신우요로상피세포암을진단받은복막투석환자에서복막뒤접근법을통한콩팥요관절제술을시행하여술후성공적인복막투석재개가가능하였다. 복막투석환자에서복부수술이필요한비뇨기계암에대한적절한치료방침이아직정립되지않은상태에서 6) 복막뒤접근법을통한수술방법은복막투석을유지하는적절한치료법이될수있다. 요 저자들은신우요로상피세포암을진단받은복막투석환자에서복막뒤접근법을통한콩팥요관절제술을시행하여복막손상을최소화함으로써성공적인복막투석재개가가능하였던증례를보고한다. 중심단어 : 재개 ; 복막투석 ; 요로상피세포암 ; 복막뒤접근 ; 콩팥요관절제술 약 REFERENCES 1) Topley N, Williams JD. Role of the peritoneal membrane in the control of inflammation in the peritoneal cavity. Kidney Int 48(Suppl):S71-S78, ) Margetts PJ, Brimble KS. Peritoneal dialysis, membranes and beyond. Curr Opin Nephrol Hypertens 15: , ) Topley N. Membrane longevity in peritoneal dialysis: impact of infection and bio-compatible solutions. Adv Ren Replace Ther 5: , ) McIntyre CW. Update on peritoneal dialysis solutions. Kidney Int 71: , ) Krediet RT, van Esch SV, Smit W, Michels WM, Zweers MM, Ho-Dac-Pannekeet MM, Struijk DG. Peritoneal mambrane failure in peritoneal dialysis patients. Blood Purif 20: , ) Kleinpeter MA, Krane NK. Perioperative management of peritoneal dialysis patients: review of abdominal surgery. Adv Perit Dial 22: , ) Pastan S, Bailey J. Dialysis therapy. N Engl J Med 338: , ) Dunnill MS, Millard PR, Oliver D. Acquired cystic disease of the kidneys: a hazard of long-term intermittent maintenance haemodialysis. J Clin Pathol 30: , ) Kojima Y, Takahara S, Miyake O, Nonomura N, Morimoto A, Mori H. Renal cell carcinoma in dialysis patients: a single center experience. Int J Urol 13: , ) Ishikawa I. Acquired renal cystic disease and its complications in continous ambulatory peritoneal dialysis patients. Perit Dial Int 12: , ) Ou JH, Pan CC, Lin JS, Tzai TS, Yang WH, Chang CC, Cheng HL, Lin YM, Tong YC. Transitional cell carcinoma in dialysis patients. Eur Urol 37:90-94, ) Kirkali Z, Tuzel E. Transitional cell carcinoma of the ureter and renal pelvis. Crit Rev Oncol Hematol 47: , ) Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, CA Cancer J Clin 48:6-29, ) Li CC, Chang TH, Wu WJ, Ke HL, Huang SP, Tsai PC, Chang SJ, Shen JT, Chou YH, Huang CH. Significant predictive factors for prognosis of primary upper urinary tract cancer after radical nephroureterectomy in Taiwanese patients. Eur Urol 54: , ) Akdogan B, Dogan HS, Eskicorapci SY, Sahin A, Erkan I, Ozen H. Prognostic significance of bladder tumor history and tumor location in upper tract transitional cell carcinoma. J Urol 176:48-52, ) Al-Qudah HS, Rodriquez AR, Sexton WJ. Laparoscopic management of kidney cancer: updated review. Cancer Control 14: , ) Manabe D, Saika T, Ebara S, Uehara S, Nagai A, Fujita R, Irie S, Yamada D, Tsushima T, Nasu Y, Kumon H. Comparative study of oncologic outcome of laparoscopic nephroureterectomy and standard nephroureterectomy for upper urinary tract transitional cell carcinoma. Urology 69: , ) Vogt J, Chlebowski H, Kniemeyer HW, Grabensee B. Successful reinstitution of CAPD after retroperitoneal repair of an aortic - S 138 -

5 - 박동원외 6 인. 복막뒤콩팥요관절제술후복막투석재개 - aneurysm: a case report. Perit Dial Int 15:71-72, ) Sicard GA, Freemann MB, VanderWoude JC, Anderson CB. Comparison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. J Vasc Surg 5:19-27, ) Sicard GA, Reilly JM, Rubin BG, Thompson RW, Allen BT, Flye MW, Schechtman KB, Young-Beyer P, Weiss C, Anderson CB. Transabdominal versus retroperitoneal incision for abdominal aortic surgery: report of a prospective randomized trial. J Vasc Surg 21: , S 139 -

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( )Jkstro011.hwp 비인강암의방사선치료결과및생존율에관한예후인자분석 2005 2 1 2005 3 28. :, Tel: 053)250-7665, Fax: 053)250-7984 E-mail: jhkim@dsmc.or.kr 정영연외 2 인 : 비인강암의예후인자분석 정영연외 2 인 : 비인강암의예후인자분석 Carcinoma of the nasopharynx treated by radiotherapy