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희애 두
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1 여성의복압성요실금치료를위한변형된수술법인 Canal Transobturator Tape 에대한예비보고 Preliminary Report on a Modified Surgical Technique Using Canal Transobturator Tape for the Treatment of Female Stress Urinary Incontinence Sung Hoon Lee, Tae Beom Kim, Khae Hawn Kim, Han Jung, Min Sung Lee, Sang Jin Yoon From the Department of Urology, Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea Purpose: Canal transobturator tape (TOT) was developed to reduce the complications of TOT by modifying the sling procedure of TOT with using a distal urethral polypropylene sling (DUPS). The aim of this present study was to describe a modified surgical technique for the treatment of female urodynamic stress urinary incontinence and to assess the objective and subjective efficacy of Canal TOT. Materials and Methods: Between October 2006 and November 2007, 87 female patients with stress urinary incontinence were enrolled in this retrospective study. All the patients underwent the Canal TOT procedure. The Incontinence Impact Questionnaire-7 (IIQ-7) and the Urogenital Distress Inventory-6 (UDI-6) were used to evaluate the surgical outcomes. Results: The mean operative time for Canal TOT was 22.4 minutes (range: 15-39). During the surgery, there were 10% intraoperative and postopreative complications, including De novo urgency (n=3), weak stream (n=4) and difficult emptying (n=2). Yet all these complications occurred in the short-term and they were transient. Concomitant procedures were performed, including cystocele repair (n=7), rectocele repair (n=5), rectocele and cystocele repair (n=14), laparoscopically-assisted vaginal hysterectomy (n=5) and total vaginal hysterectomy (n=1). The average follow-up was 4.5 months (range: 3-12). Both the mean IIQ-7 and UDI-6 scores significantly decreased after Canal TOT and all the patients showed significant improvement of their subjective symptoms of stress incontinence. Conclusions: Our results demonstrate that Canal TOT may be a safe and effective surgical method for treating urodynamic stress incontinence in Korean women and this procedure provides a high cure rate. (Korean J Urol 2008;49: ) Key Words: Stress urinary incontinence, Suburethral sling 대한비뇨기과학회지제 49 권제 12 호 2008 가천의과학대학교의학전문대학원비뇨기과학교실 이성훈ㆍ김태범ㆍ김계환정한ㆍ이민성ㆍ윤상진 접수일자 :2008년 6월 27일채택일자 :2008년 10월 8일 교신저자 : 김계환가천의과학대학교길병원비뇨기과인천시남동구구월동 1198 번지 TEL: FAX: kimcho99@ gilhospital.com 서론현대사회에서생활수준이향상되고삶의질에대한관심이증가되면서요실금은참고지내는질환이아니라적극적으로치료를요하는질환으로인식이변화되고있다. 요실금은주로중년이후의여성에게흔하며, 이중에서복 압성요실금은여성요실금의가장흔한원인으로복압의상승과함께증가된방광내압력이요도압력보다높아져불수의적으로요의누출이생기는질환이다. 1 발생기전에따라요도의과이동성으로생기는해부학적요실금과내인성요도괄약근기능부전으로나타나는요실금으로나누어진다. 2 정상적인해부학적구조를가진여성에서는치골자궁경부근막 (pubocervical fascia) 이요도를지지하여복압 1119

2 1120 대한비뇨기과학회지 : 제 49 권제 12 호 2008 상승시방광경부의하강을막고요도를압박하여요의누출을막는데, 치골자궁경부근막이요도를적절하게지지해주지못하면요실금이발생하게된다. 그동안여러가지의복압성요실금수술방법들이고안되어시행되어왔으나 1996년 Ulmsten 등 3,4 이통합이론 (integral theory) 에근거한 tension-free vaginal tape (TVT) 을소개한이후, 전세계적으로중부요도슬링이널리보급되어단기적으로우수한성공률을보였고장기추적에서도높은성공률이유지되어많이시행되었으나창상감염, 요로감염, 혈종형성, 방광천공, 장손상, 혈관또는신경손상, 수술후배뇨장애등의합병증이지속되어치골후경로 (retropubic route) 를통하지않는경폐쇄공경로 (transobturator route) 의수술법이고안되었다. 경폐쇄공테이프 (transobturator tape; TOT) 술식은안정적이고효율적이어서현재여성의복압성요실금에많이사용되고있다. 하지만여전히질미란, 요도손상, 수술후배뇨장애등이보고되고있어서이에저자들은 Rodriguez와 Raz 5,6 가소개한 distal urethral polypropylene sling (DUPS) 술식에서착안한변형된 TOT 방법인 Canal TOT를시행하였으며, Incontinence Impact Questionnaire-7 (IIQ-7) 과 Urogenital Distress Inventory-6 (UDI-6) 를이용하여객관적인삶의질에미치는영향과주관적인증상호전정도를알아보고자하였다. 7 대상및방법 1. 대상 2006년 10월부터 2007년 2월까지, 2007년 5월부터 2007 년 11월까지본원에서복압성요실금으로진단받고, 동일술자에게 Canal TOT 술식을시행받은환자중에서 3개월이상추적관찰한 87명을대상으로하였으며, 절박성요실금증상정도가복압성요실금증상과비슷하거나더심한경우는제외하였고, 신경인성방광, 요로감염, 요로결석등의방광기능이상을발생시킬수있는질환을가진환자들은제외하였으며, 수술결과및환자의주관적만족도를진료기록을통하여후향적으로분석하였다. 모든환자는수술전검사로자세한병력청취, 신체검사, 소변검사및배양검사, 발살바요누출압 (Valsalva leak-point pressure; VLPP) 검사를포함한요역동학검사를시행하였으며, 수술전과후에환자의주관적만족도는자가기입설문지 (IIQ-7과 UDI-6) 를이용하여평가하였다. 7 UDI는객관적인배뇨증상자체를평가하며각문항당 0점에서 3점까지로총점이 300 점이며, IIQ는일상생활에서배뇨증상으로인한불편감을측정하며각문항당 0점에서 3점까지로총점이 400점이고, 점수가높을수록일상생활에배뇨증상이미치는영향이크 며, 삶의질이낮은것으로평가된다. 8 IIQ-7과 UDI-6는 IIQ 와 UDI의축약형으로간단하면서도환자들에게쉽게이해되어널리사용되고있다. 7 통계학적분석은 SPSS 12.0.k을이용하여 paired t-test를시행하였고, p값이 0.05 미만인경우를통계학적으로유의한것으로판정하였다. 2. 수술방법 요도입구에서 1.5cm 떨어진질전벽 (anterior vaginal wall) 에양외측으로 1.5cm 정도의절개를시행후동측어깨방향바깥쪽으로요도주위근막이보이도록박리한다. 직각집게 (right angle clamp) 를이용하여질전벽의요도입구로부터하방약 1cm에하부요도터널을만든후테이프를하부요도터널로통과시킨다. 음핵 (clitoris) 에평행하게음부하퇴주름 (genito-crural fold) 0.5cm 내측에 0.5cm 정도의절개를시행한후검지로질전벽의절개부위를통과하여폐쇄공막 (obturator membrane) 에대고나선형트로카 (helical trocar) 의터널침이바깥절개부위에서폐쇄공막을통과하여질전벽의절개부위로들어오는것을유도한다. 테이프를절개부위로빠져나온터널침에연결하여다시음부하퇴주름을통과시켜폐쇄공에위치하게한다. 음부하퇴절개부위로테이프가나오도록한후에, 2개의질전벽절개부위를통해집게 (allis forceps) 로테이프를잡고무긴장 (tension free) 을유지시키면서양외측음부하퇴주름부위의테이프를제거한다. 절개부위를 3번흡수성봉합사로단순봉합후베타딘젖은거즈로질메우기를시행한다. 방광류복원술 (cystocele repair) 을하는경우에는봉합된양측절개부위의근위부에서부터전질벽중앙을절개하여 cystocele 교정을진행한다. 결 대상환자의평균연령은 54세 (34-81), 이전자궁적출술을시행받은환자는 7명 (8%), 평균자연분만횟수는 2.1명 (0-6) 이었다 (Table 1). 평균수술시간은 22.4분 (15-39), 평균재원기간은 3일 (2-6), 수술전과후의혈색소 (hemoglobin) Table 1. The preoperative patients characteristics Characteristic 과 Median age (range) Menopausal patients (%) No. of prior hysterectomy (%) Median No. of vaginal deliveries (range) 54(34-81) 46/87 (53) 7/87(8) 2.1 (0-6)

3 이성훈외 : 여성의복압성요실금치료, Canal Transobturator Tape 1121 변화는 0.67g/dl (0-2.3) 였다 (Table 2). 요실금수술과동시에방광류복원술 7명, 직장류복원술 5명, 방광류및직장류복원술동시시행 14명, 복강경유도질식자궁적출술 5명, Table 2. The operative data Postoperative results (sling only) Median (range) Operation time (minutes) 22.4 (15-39) Hemoglobin change (g/dl) 0.67 (0-2.3) Hospital stay (days) 3 (2-6) Follow up (total) (month) 4.5 (3-12) Concomitant procedure No. of patients (%) Sling alone 55 (63) Cystocele repair 7 (8) Rectocele repair 5 (6) Cystocele, rectocele repair 14 (16) Cystocele, rectocele repair, VTH 5 (6) Cystocele, rectocele repair, LAVH c BSO, staging op. 1(1) Intraoperative and short-term complications No. of patients (%) Bladder perforation 0 (0) De novo urgency (transient) 3 (3) Weak stream 4 (5) Hematoma in Retzius' space 0 (0) Difficult emptying 2 (2) Long-term complications No. of patients (%) Urinary obstruction 0 (0) Inguinal pain 0 (0) Mesh erosion 0 (0) Dyspareunia 0 (0) VTH: vaginal total hysterectomy, LAVH: laparoscopic-assisted vaginal hysterectomy, BSO: bilateral salphingo-oophorectomy 개복질식자궁적출술 1명을시행하였다 (Table 2). 수술과관련된방광, 장, 혈관손상, 혈종형성같은주요한합병증은없었고, 단기합병증으로는일시적절박뇨 3명 (3%), 약한배뇨 4명 (5%), 급성배뇨장애 2명 (2%) 이있었다 (Table 2). 수술전 IIQ-7와 UDI-6 평균은 1.35, 1.40이었으며, 수술후에는 0.10, 0.17으로유의하게감소하였고 (Table 3, 4), 모든항목에서유의하게감소한소견을보였다. 고찰복압성요실금은여성요실금의흔한형태로복압이상승하면서방광경부가열려배뇨근의수축없이복압이상승할때불수의적으로요누출이일어나는질환으로서, 골반강내근육의이완으로방광경부및후부요도가변위되어급작스런복압증가시방광내로전달되는압력에비해서방광경부및후부요도에전달되는압력이낮음으로인해서발생되거나 9 선천적으로요도가짧거나요도괄약근기능이약한경우에서도나타날수있다. 10 과거의요실금수술은복압상승시방광경부와전부요도의과운동성으로발생하는해부학적요실금에서는방광경부현수술을시행하였고, 요도자체의손상및약화로인한내인성요도괄약근기능부전에서는슬링수술을진행하였으나재발및합병증이지속되어기존수술법의단점을보완하고, 비침습적이고, 당일수술및퇴원이가능하면서도, 재발및합병증이적어일상생활로의조기복귀가가능한수술방법을지속적으로찾게되었다 년 Ulmsten 등 4 은기존의요도압전달이론 (pressure-transmission theory) 과는달리요도주위를지지하는치골요도인대가느슨해져서요실금이발생하며, 따라서복압성요실금을치료하기위해서는이치골요도인대가위치하고있는중부요도를지지해줘야한다는 integral 이론에기초한 TVT 술식을발표하였으며, 수술이간편하여배우기가쉽고수술시간, 입원기간이짧으며, 장 Table 3. The results of the preoperative and postoperative Incontinence Impact Questionnaire (IIQ)-7 IIQ-7 (%) Preoperative Postoperative p-value Has urinary leakage and/or prolapse affected your: 1. Household chores 1.60± ±0.30 < Physical reaction 1.64± ±0.34 < Entertainment activities 1.77± ±0.51 < Travel over 30 minutes away from home 1.38± ±0.33 < Social activities 1.68± ±0.44 < Emotional health (nervouness, depression, etc) 1.18± ±0.26 < Feeling frustrated 0.24± ±0.18 <0.001 p-value: paired t-test, Score: 0=not at all, 1=slightly, 2=moderately, 3=greatly

4 1122 대한비뇨기과학회지 : 제 49 권제 12 호 2008 Table 4. The results of the preoperative and postoperative Urogenital Distress Inventory (UDI)-6 Preoperative Postoperative p-value Do you experience, and, if so, how much are you bothered by: 1. Frequent urination 1.62± ±0.51 < Leakage related to feeling of Urgency 0.51± ± Leakage related to activity, coughing, or sneezing 2.38± ±0.39 < Small amounts of leakage (drops) 1.69± ±0.46 < Difficulty emptying bladder 1.53± ±0.39 < Pain or discomfort in lower abdominal or genital area 0.68± ±0.26 <0.001 p-value: paired t-test, Score: 0=not at all, 1=slightly, 2=moderately, 3=greatly 기성적도우수한방법으로평가되어널리시행되었다. 3,4 또한해부학적요실금뿐만아니라내인성요도괄약근기능부전에의한요실금에서도 80% 이상의성공률을보이며, 12 고령의환자에서도우수한성적이보고되었다. 13 그러나방광천공이나요도미란으로인해테이프가방광이나요도내에위치하거나혈관손상, 장천공 14,15 등의심각한합병증이보고되어, Delorme 16 은 2001년치골뒤공간 (retzius space) 을통과하지않고방광천공및혈관손상등의합병증위험을줄일수있는 TOT를소개하였다. TOT 술식은좌골치골가지의후면을따라서폐쇄공을통하여진입하기때문에치골후경로를통과하는 TVT 술식보다방광, 장, 신경및혈관손상의위험이적으며, 또한테이프가폐쇄혈관및신경과거리를두고통과하기때문에이들구조물에대한손상위험도적다. 17 또한 TOT 술식은 TVT 술식보다요도주위에대한압박이적어요폐증상이더적게나타난다. 18 Seok 등 19 의경우에도 TOT 술식후 14% 에서경도의배뇨곤란을호소하였는데, 이는 Mazouni 등 20 이 TVT 술식이후발생했다고보고한 60% 의배뇨곤란보다낮았다. TOT 술식에는 outside-in 방식의 Monarc와 inside-out 방식의 TVT-O의두가지방식이있으며, Monarc 는질전벽의중앙절개후양측폐쇄공내측까지박리하고검지를통하여터널기구를인도하기때문에 TVT-O에비해질전벽의박리가넓어져질손상및미란, 또는요도손상에노출될가능성이있으나터널기구가통과하는위치부터폐쇄혈관이나신경이지나가는폐쇄관까지거리가 Monarc가 TVT-O보다멀기때문에보다더안전하였다. 21 Rodreguez와 Raz 5,6 는치골요도인대 (pubourethral ligaments), 요도압박근 (compressor urethrae), 요도질괄약근 (urethrovaginal sphincter), 원위요도 (distal urethra) 후벽 (posterior wall) 과연결된골반지지근육 (levator muscle) 등으로구성된원위요도복합체 (distal urethral complex) 개념을 2003년에소개하였으며, 이러한원위요도복합체가요도의수동적, 능동적인긴장도를조절하는것으로보고하였다. 원위요도부위 는치골에더근접하여있어, 원위요도슬링은요도후방을지지하여원위요도부위의부분적인저항을증가시키고복압증가시요도에서골반근육 (levator muscle) 의지지효과를증가시키며중부요도와원위요도, 그리고방광경부가저항없이유지된다. 수술후에발생하는배뇨장애의한형태로수술의만족도에부정적인영향을미치는새로발생한요절박 (de novo urgency) 의경우 DUPS (0-7.2%), 22,23 Burch colposuspension (22.2%), 24 pubovaginal sling (19%), 25 TVT (6-14.5%) 23,26 로원위요도슬링술식이다른술식에비해부작용이적은것으로보고되었다. 이에원위요도복합체개념을후치골통로에적용한 DUPS에서폐쇄공통로로전환한 Canal TOT를시행하여, 초기자료 (preliminary data) 를수집하였으며본연구에서의수술후새로발생한요절박의경우 3% 의빈도를보였다. Canal TOT는질전벽의양측에절개를하기때문에 Monarc보다총절개부위는더넓지만양측폐쇄공내측까지검지의접근이쉬워고도비만등의드문경우에더수술이용이하고, 터널기구의질손상여부확인이용이하며양측절개부위사이에터널을만들고테이프를위치하여수술후에테이프의위치가이동하지않게되고, 드물지만 Monarc 수술후질전벽의넓은박리로인하여테이프의위치가중부요도에서방광경부로이동하여발생하는요실금증상과동반된배뇨장애가나타나지않았다. 저자들이시행한 87례의 Canal TOT의경우요실금수술의일반적인합병증인창상감염, 요로감염, 혈종형성, 방광천공, 장손상, 혈관또는신경손상, 질미란, 요도손상등은보이지않았으며, 수술후일시적인절박뇨, 약한배뇨및배뇨장애소견이있었으나, 장기적인배뇨장애및합병증은나타나지않았다. 중부요도슬링의 TOT와비교했을때전질벽에 2개의절개창을사용한다는것이논쟁이될수는있으나양쪽절개창을통하여터널을만들어테이프를위치하여테이프가원위요도에잘위치할수있도록하며, 양측절개창에서테이프를움직여서장력을잘조절할수있으며, 수술후의

5 이성훈외 : 여성의복압성요실금치료, Canal Transobturator Tape 1123 배뇨장애와성교통은일시적으로는나타났으나 3개월이후에는나타나지않았다. 질전벽의양쪽절개선을봉합하고나면, 봉합선이보이지않고촉지되지않아술후환자의주관적인만족도가높았다. 실제적인배뇨증상을측정하는 UDI-6에서대부분의환자들이모든항목에서요실금증세가유의하게호전되었으며 (Table 4), 요실금으로인한일상생활에서의불편감을측정하는 IIQ-7에서또한환자들의불편감이유의하게호전되었다 (Table 3). 결 변형된 TOT방법인 Canal TOT를이용한여성복압성요실금의수술은약 1년간의추적조사에서의환자만족도에서우수한성적을보였다. 수술후합병증도거의나타나지않았으며, 주관적만족도에서대부분의환자들이요실금증세가없어졌다고하였으며, 일상생활에서의불편감또한유의하게감소하였다. 그러나장기추적검사및기존의중부요도를이용한 TOT와충분한비교분석이아직부족한상태이므로추가적인연구가필요할것으로생각한다. 론 REFERENCES 1. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 2003;61: Blaivas JG, Romanzi LJ, Heritz DM. Urinary incontinence: pathophysiology, evaluation, treatment overview and nonsurgical management. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ, editors. Campbell s urology. 7th ed. Philadelphia: Saunders; 1998; Petros PE, Ulmsten UI. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand 1990;153(Suppl): Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996;7: Rodriguez LV, Raz S. Polypropylene sling for the treatment of stress urinary incontinence. Urology 2001;58: Rodriguez LV, Raz S. Prospective analysis of patients treated with a distal urethral polypropylene sling for symptoms of stress urinary incontinence: surgical outcome and satisfaction determined by patient driven questionnaires. J Urol 2003;170: Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995;14: Shumaker SA, Wyman JF, Uebersax JS, McClish D, Fantl JA. Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program in Women (CPW) Research Group. Qual Life Res 1994;3: Lam TC, Hadley HR. Surgical procedures for uncomplicated ( routine ) female stress incontinence. Urol Clin North Am 1991;18: Haab F, Zimmern PE, Leach GE. Female stress urinary incontinence due to intrinsic sphincteric deficiency: recognition and management. J Urol 1996;156: Yoo JW, Jung HC. Tension free vaginal tape procedure for the treatment of female stress urinary incontinence: 1 year follow up. Korean J Urol 2001;42: Paick JS, Ku JH, Shin JW, Son H, Oh SJ, Kim SW. Tension-free vaginal tape procedure for urinary incontinence with low Valsalva leak point pressure. J Urol 2004;172: Ku JH, Oh JG, Shin JW, Kim SW, Paick JS. Age is not a limiting factor for midurethral sling procedures in the elderly with urinary incontinence. Gynecol Obstet Invest 2006;61: Zilbert AW, Farrell SA. External iliac artery laceration during tension free vaginal tape procedure. Int Urogynecol J Pelvic Floor Dysfunct 2001;12: Amna MB, Randrianantenaina A, Michel F. Colic perforation as a complication of tension-free vaginal tape procedure. J Urol 2003;170: Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 2001;11: Achtari C, McKenzie BJ, Hiscock R, Rosamilia A, Schierlitz L, Briggs CA, et al. Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings. Int Urogynecol J Pelvic Floor Dysfunct 2006;17: Davila GW, Johnson JD, Serels S. Multicenter experience with the Monarc transobturator sling system to treat stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2006;17: Seok NS, Suh HJ, Lee DH. Clinical outcome of transobturator Monarc procedures for treating of women with stress urinary incontinence: 2-year follow up. Korean J Urol 2006;47: Mazouni C, Karsenty G, Bretelle F, Bladou F, Gamerre M, Serment G. Urinary complications and sexual function after the tension-free vaginal tape procedure. Acta Obstet Gynecol Scand 2004;83: Whiteside JL, Walters MD. Anatomy of the obturator region: relations to a trans-obturator sling. Int Urogynecol J Pelvic

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<30375FBFF8C0FA5FC0CCC1A4C1D62E687770> 대한배뇨장애요실금학회지 J Korean Continence Soc 2008;12:139-44 원저 60 세이상여성요실금환자에서의 TOT 술식의성적 부산대학교의과대학비뇨기과학교실 Outcomes of the Transobturator Tape Procedure for Elderly Women above 60 Years Old with Stress Urinary