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1 신동맥결찰없이수술한복강경부분신절제술 Laparoscopic Partial Nephrectomy without Renal Arterial Clamping Hye Min Hong, Ill Young Seo, Joung Sik Rim From the Department of Urology, Wonkwang University School of Medicine, Iksan, Korea Purpose: Renal vascular clamping during a laparoscopic partial nephrectomy is a time-consuming procedure with a risk of renal ischemia. To study the feasibility of laparoscopic partial nephrectomy without renal arterial clamping, we compared the procedure with laparoscopic partial nephrectomy with vascular clamping. Materials and Methods: Seventeen patients underwent laparoscopic partial nephrectomy without renal arterial clamping (group 1) from February 24 to June 2. The operative results were reviewed retrospectively and compared with those of 1 patients who underwent laparoscopic partial nephrectomy with arterial clamping (group 2). Patient characteristics did not differ significantly between the 2 groups. However, exophytic tumors were detected in 13 patients in group 1 and 3 patients in group 2 (p=.1). Scores on the preoperative aspects and dimensions used for an anatomical (PADUA) classification were. in group 1 and 7.7 in group 2 (p=.37). All surgeries by the transperitoneal approach were performed by a single surgeon. Results: The mean operative times were 13 and 13 minutes in groups 1 and 2, respectively (p=.312). The mean renal arterial clamping time of group 2 was 27. minutes (range, 2-42 minutes). The mean estimated blood loss was 327 ml in group 1 and 315 ml in group 2 (p=.71). The mean postoperative change in the glomerular filtration rate was 2.11 ml/min/1.73 m 2 in group 1 and 1.5 ml/min/1.73 m 2 in group 2 (p=.74). The mean times to postoperative initiation of ambulation and of oral intake were 1. and 1.7 days (p=.4) and 1.3 and 1. days (p=.11) in groups 1 and 2, respectively. The mean length of hospital stay was 7.4 and 7. days in groups 1 and 2, respectively (p=.). The mean tumor size was 2.1 cm (range, 1-7 cm) in group 1 and 3.3 cm (range, 1.5- cm) in group 2. Conclusions: Laparoscopic partial nephrectomy without renal arterial clamping is feasible for a localized renal tumor. However, patients should be selected carefully, such as those with an exophytic tumor. (Korean J Urol 2;5: ) Key Words: Kidney neoplasms, Laparoscopy, Nephrectomy Korean Journal of Urology Vol. 5 No. 12: , December 2 DOI: /kju 원광대학교의과대학비뇨기과학교실 홍혜민ㆍ서일영ㆍ임정식 Received:May 21, 2 Accepted:November, 2 Correspondence to: Ill Young Seo Department of Urology, Wonkwang University School of Medicine, 344-2, Shinyong-dong, Iksan , Korea TEL: FAX: seraph@wonkwang.ac.kr C The Korean Urological Association, 2 절제술이선택되고있으며, 크기가작은국소신장암의경 서 론 우에는복강경부분신절제술이가능해졌다. 신기능을보전 할수있는부분신절제술은근치적신절제술에비하여고도 11년 Clayman 등이복강경신절제술성공을보고 [1] 한 의기술을필요로하지만지속적인술기의발전으로가능 이후비뇨기과영역의복강경수술은많은발전을이루고 해졌으며, 최근에는근치적신절제술과비교하여종양조절 있다. 신장암에대한표준치료방법으로복강경근치적신 효과가비슷한것으로보고되고있다 [2,3]. 12

2 Hye Min Hong, et al:laparoscopic Partial Nephrectomy 12 복강경부분신절제술은덜침습적인수술방법으로, Winfield 등의보고 [4] 이후적응증이확대되어종양의크기가작은국한된신암에대해서도시도되고있다 [5,]. 그러나아직까지술기가어려운도전적인수술법이며, 특히수술중출혈을방지하기위해일시적으로신혈관을결찰하는과정이필요하다 [7]. 신동맥및정맥을박리하기위해서는수술시간이추가로소요되며, 신동맥결찰로인한신허혈위험이있어신동맥결찰시간을최소화해야하는등술기의제한이있다. 저자들은신동맥을결찰하지않고복강경부분신절제술을시행하였으며, 그결과를신동맥을결찰한경우와비교하여, 신혈관결찰없이시행한복강경부분신절제술의가능성에대해알아보고자하였다. 대상및방법 24년 2월부터 2년 월까지본원에서복강경부분신절제술을받은환자중에서추적검사가가능했던 34명중술중종물의크기가커서수술공간의부족으로개복을하였던한명을제외한 33명을대상으로하였으며, 모든수술은단일술자에의해서이루어졌다. 이중신동맥을결찰하지않고복강경부분신절제술을받은환자는 17명 (1군) 이었으며, 신동맥을결찰하고수술을받은환자는 1명 (2 군 ) 이었다. 평균연령은 1군에서 55.5세 (24-74), 2군에서 54.세 (25-7) 이었고, 남녀비는 1:2.4와 1:1이었으며, 평균체질량지수는 23. kg/m 2 ( ) 와 24.1 kg/m 2 ( ) 로두군간에차이가없었다. 제1군에서 7명, 2군에서 2명이복부수술의과거력이있었다. 모든환자에서수술전에복부전산화단층촬영을실시하여종양의위치및크기, 신혈관개수등을확인하였다. 종양은 1군에서좌측 례, 우측 례였으며, 2군에서는좌측 례, 우측 1례였다. 종양의위치는 1군에서신상극 례, 중극 4례, 하극 5례였으며, 2군에서신상극 3례, 중극 례, 하극 7례로두군간의차이가없었다. 복부전산화단층촬영사진에서종양의 5% 이상이신실질밖에위치한경우를돌출된종양으로정의하였고, 제1군에서 13명, 2군에서는 3명으로신동맥을결찰하지않은군에서돌출된종양이더많았다 (p=.1). 또한 Preoperative Aspects and Dimensions Used for An anatomical (PADUA) 분류방법을이용하여모든환자를분류하였으며 1군에서.점 (-), 2군에서 7.점 (7-) 으로신동맥을결찰하지않은군에서신동맥을결찰하지않은군에서돌출된종양이많아점수가더낮았다 (p=.37) (Table 1) []. 복강경부분신절제술은모두경복막접근법으로이루어졌다. 종물의위치를찾기어려운경우에는복강경초음파를이용하여종물을확인하였다. 제2군에서는신문부를박리하여신동맥과정맥을노출시킨후불독겸자를이용하여신동맥을결찰하였다. 종양의절제는제1군의경우출혈을 Table 1. Patient characteristics No. of patients Mean age (years) Male to female ratio Mean BMI (kg/m 2 ) History of abdominal operation Tumor laterality Left Right Tumor location Upper pole Mid pole Lower pole Exophytic tumor PADUA score (24-74) 1: ( ) 7 (2: appendectomy, 1: ovarian cyst excision, 1: nephrectomy, 1: transabdominal hysterectomy, 1: partial nephrectomy, 1: subtotal gastrectomy) (-) (25-7) 1: ( ) 2 (1: adhesiolysis, 1: renal cyst excision) (7-).2 a.11 b.2 a.31 b.34 b.4 b.37 a BMI: body mass index, PADUA: preoperative aspects and dimensions used for an anatomical classification, Group 1: laparoscopic partial nephrectomy without renal arterial clamping, Group 2: laparoscopic partial nephrectomy with renal arterial clamping, a : Mann-Whitney U test, b : Pearson chi-square test

3 121 Korean Journal of Urology vol. 5, , December 2 방지하기위해서초음파메스 (SonoSurg R, Olympus optical, Japan) 를이용하였고, 제2군의경우에는복강경가위를이용하여종물과 5 mm 이상떨어진경계부위를절제하였다. 종양을절제한후냉동생검은시행하지않았으며, 절제한기저부를추가로절제하여병리검사에이용하였다. 절제된조직을복강경주머니에넣어제거하였다. 절제부위의출혈은 argon beam 소작기, fibrin sealant (Tissucol R, Baxter AG, Austria), cellulose mesh (Surgicel R, Ethicon Inc., USA) 등을이용하여조절하였으며, 손상된집뇨계는폴리머클립 (Hem-o-lok R, Weck closure systems, USA) 이고정된 Vicryl 3-사를이용하여연속봉합하였고신실질내에흡수성봉합클립 (Lapra-Ty R, Ethicon Inc., USA) 으로매듭을만들었다. 피막을포함한신실질은 Vicryl 2-사와흡수성봉합클립으로봉합하였다. 두군에서수술결과를후향적으로비교하여분석하였다. 신기능의변화를알기위해술전, 술후 1일째, 그리고술후추적관찰중에혈청 creatinine을측정하였다. 술전과 술후 1일째, 그리고술후추적관찰중의사구체여과율을 Modification of Diet in Renal Disease Study Group (MDRD) 연구의공식인 GFR (in ml per minute per 1.73 m 2 )=1x scr xage.23 (x.742 여성일경우 ) 를이용하여계산하였다 [,1]. 통계처리는 SPSS 12.K for Windows 통계프로그램을이용하였고 Mann-Whitney U test와 Pearson chi-square test로분석하였으며, p값이.5 미만인경우통계학적으로유의한것으로판정하였다. 결과평균수술시간은 1군에서 13분 (-1), 2군에서 13분 (-24) 으로신동맥을결찰한군에서더길었으나통계학적인차이는없었다 (p=.312). 제2군에서신동맥결찰시간은평균 27.분 (2-42) 이었다. 두군의평균출혈량은 327 cc와 315 cc로통계적인차이는없었다 (p=.71). 수술과관련된합병증은 2군에서 2명발생하였다. 한명은수술중 Table 2. Operative results Operation time (minutes) Estimated blood loss (cc) Postoperative initiation of ambulation (days) Postoperative initiation of intake (days) Hospital stay (days) 13 (-1) 327 (7-) 1. (1-4) 1.3 (1-2) 7.4 (5-11) 13 (-24) 315 (5-) 1.7 (1-4) 1. (1-4) 7. (5-14) Group 1: laparoscopic partial nephrectomy without renal arterial clamping, Group 2: laparoscopic partial nephrectomy with renal arterial clamping Table 3. Pathologic results of renal tumors Mean mass size (cm) Pathologic results RCC AML Adenoma Positive surgical margin 2.1 (1-7) 3.3 (1.2-) 1.57 a.743 b RCC: renal cell carcinoma, AML: angiomyolipoma, Group 1: laparoscopic partial nephrectomy without renal arterial clamping, Group 2: laparoscopic partial nephrectomy with renal arterial clamping, a : Mann-Whitney U test, b : Pearson chi-square test Table 4. Difference in the glomerular filtration rate in patients who underwent partial nephrectomy Difference of GFR between preoperation and POD1 (ml/min/1.73 m 2 ) Difference of GFR between preoperation and last follow-up (ml/min/1.73 m 2 ) Group 1 Group 2 p-value GFR: glomerular filtration rate, POD: postoperative day, Group 1: laparoscopic partial nephrectomy without renal arterial clamping, Group 2: laparoscopic partial nephrectomy with renal arterial clamping.74.17

4 Hye Min Hong, et al:laparoscopic Partial Nephrectomy 1211 간손상이발생하였으나보전적인치료로치료되었고, 다른한명은술후수술부위탈장이발생하여외과에서수술받았다. 수술후평균보행개시일은 1군에서 1.일, 2군에서 1.7일이었고, 평균식이개시일은 1.3일과 1.일이었다 (p=.4,.11). 평균재원기간은 7.4일과 7.일로의의있는차이는없었다 (p=.) (Table 2). 적출된조직의병리검사에서 1군의경우종양의크기는평균 2.1 cm (1-7) 였으며, 신세포암 례, 혈관지방종 례였다. 제2군의경우종양의크기는평균 3.3 cm (1.2-) 였으며, 신세포암 례, 혈관지방종 례, 선종 1례였다. 두군모두에서절제면양성소견은관찰되지않았다 (Table 3). 제1군에서수술전과수술후 1일째의사구체여과율의차이는 1.5 ml/min/1.73 m 2 였으며, 2군에서는 2.11 ml/min/1.73 m 2 로두군간의의미있는차이는없었다 (p=.74). 수술전과추적관찰기간중의사구체여과율의차이도 1군에서 21. ml/min/1.73 m 2, 2군에서 1.4 ml/min/ 1.73 m 2 으로의의있는차이가없었다 (p=.17) (Table 4). 수술후평균추적기간은 1군에서 2.1개월 (-3), 2군에서 31.3개월 (-4) 이었으며추적기간중실시한방사선검사에서종물의재발은없었다. 고찰복강경부분신절제술은신기능을보전할수있는장점이있어일측신을가진신장암환자혹은양측신기능에장애가있는환자에서표준적치료로이용되고있다 [5-7,11]. 최근에는그적응증이확대되어크기가작은국소신장암환자에서성공적인치료방법으로보고되고있다. 특히, 영상의학의발전으로국소신장암의발견율이높아지면서복강경부분신절제술에대한관심은높아지고있으며실제로 4 cm 이하의신종양의치료로복강경부분신절제술의적용이증가하고있는추세이다. 복강경부분신절제술의술기중가장중요한부분중하나가지혈이다. 따라서수술중출혈을예방하기위해서일반적으로신혈관을결찰하게된다. Ramani 등의연구에서는초기복강경부분신절제술을시행받은환자 2명의합병증을조사하였으며, 조사결과 3명의환자에서부작용이발생하였고, 그중신출혈이 21명으로가장큰비중을차지하였으며이는신동맥의불충분한결찰에서기인한것이라고보고하였다 [12]. Guillonneau 등은신동맥를결찰한복강경부분신절제술환자군과신동맥결찰을하지않고수술한군을비교하였으며결찰한군에서의출혈량은평균 27 cc였으나, 결찰하지않은군에서의출혈량은 7 cc로 결찰하지않은군에서의출혈량이유의하게많았다고보고하였다 [13]. 그러나신동맥결찰과정에수술시간이소요되며, 박리과정중에신혈관이손상될수있으며, 신혈관결찰시간이길경우신허혈이발생할수있다 [14]. Desai 등은 7세이상의고령이나술전크레아틴수치가 1.5 mg/dl인환자에서 3분이상의신동맥결찰시술후신기능저하가올수있다고보고하였으며 [14], Kobayashi 등도비슷한결과를보고하였다 [15]. 따라서신동맥결찰을시행한복강경부분신절제술에서는신동맥결찰후 3분이내에부분신절제술을시행해야하는시간의제한이있으며고령의환자나술전신기능이감소된환자에서술후신기능저하가능성이존재한다. 신허혈로인한신기능감소를줄이기위해여러가지냉각요법들이보고되었다. Landman 등이처음동물모델에서복강경부분신절제술시신실질냉각요법을보고하였으며 [1], Janetschek 등은신동맥으로통과된카테터에냉각수를주사하며수술한부분신절제술 15례를보고하였다 [17]. 그러나이런방법들은복강경수술로시행하기가어렵고신냉각효과도만족스럽지못하다. 따라서, 최근에는신혈관을결찰하지않고시행한복강경부분신절제술이보고되고있다. 신동맥결찰없이시행한복강경부분신절제술은신동맥결찰후시행한수술에비하여술후허혈이발생하지않는장점이있으며, 종양의크기가작고외부로돌출된경우엔복강경부분신절제술시신동맥을결찰하지않고도수술이가능하였다. 또한수술결과에서결찰한경우와의의있는차이가없었다. Venkatesh 등은신밖으로돌출된종양에서신동맥을결찰한군과결찰하지않은군에서합병증의증가가일어나지않았다고보고하였다 [1]. Finley 등은 1 cm 미만의신종물에서 샌드위치 방식으로시행한복강경부분신절제술을보고하였으며 [1], Jeon과 Kim은평균 2.3 cm의신종양환자에서신동맥결찰없이 샌드위치 방식으로 Floseal, Surgicel, Tisseel 등을이용한복강경부분신절제술을보고하였다 [2]. Fogarty 등도 4 cm 이하의신종양을신동맥결찰없이복강경부분신절제술로치료한것을보고하였다 [21]. 저자들의경우도신동맥결찰없이복강경부분신절제술을성공적으로시행하였다. 결찰하지않은군과비교할때기본적인조건은같았으나결찰하지않은군에서돌출된종양의빈도가높았다. 그러나수술결과에서수술시간및출혈량등에의의있는차이가없었다. 즉신장밖으로돌출된종양의경우신동맥결찰없이도부분신절제술이가능함을알수있었다. 통계적인차이는없었지만, 복부수술의과거력이있는경우에신문부박리의위험때문에상대적으로신동맥을결찰하지않은경우가더많았던것으로추측

5 1212 Korean Journal of Urology vol. 5, , December 2 된다. 술기적인문제로, 신동맥을결찰하지않은경우적절한지혈과빠른봉합을위해서종양을절제할때초음파메스를이용하여지혈을하면서조직을절제하였다. 집뇨계의봉합은폴리머클립을이용하여연속적으로봉합하였고흡수성클립으로결찰하였으며, 신실질의봉합도폴리머클립을이용하여연속적으로봉합하였다. 이방법을이용할경우신실질을압박하면서빠르게봉합할수있어지혈및수술시간단축에효과적이다 [21]. 수술전후의사구체여과율은환자수술후금식과혈액손실량에따른체중변화를고려하여 MDRD 연구의공식을이용하여계산하였다. 수술후신기능의변화에대한저자들의결과, 신동맥을결찰한군과비교하였을때유의한차이가없어동맥결찰시간이짧다면동맥결찰유무가신기능변화에영향을미치지않을것으로추측된다. 그러나저자들의신기능평가방법이혈청 creatinine과사구체여과율만을이용하였으므로분리신기능을완전히평가하지는못하였다. 결 국한된신장종양에대해서신동맥을결찰하지않고서도복강경부분신절제술이가능하다. 특히, 신장밖으로종양이돌출된경우적용이가능하다. 그러나종양절제후지혈및봉합에대한적절한술기가필요하므로복강경수술에대한충분한경험이필요할것으로생각한다. 또한수술후신기능의변화에대한분리신기능평가방법을적용하기위해서전향적인연구가필요할것이다. 론 REFERENCES 1. Clayman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, et al. Laparoscopic nephrectomy: initial case report. J Urol 11;14: Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 1-years follwup. J Urol 2;13: Lerner SE, Hawkins CA, Blute ML, Grabner A, Wollan PC, Eickholt JT, et al. Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. 1. J Urol 22;17: Winfield HN, Donovan JF, Godet AS, Clayman RV. Laparoscopic partial nephrectomy: initial case report for benign disease. J Endourol 13;7: Hong SH, Ryu KY, Yoo JS, Seo SI, Kim JC, Hwang TK. Laparoscopic partial nephrectomy for the 4cm or less renal tumors. Korean J Urol 2;47: Seo IY, Bae BJ, Rim JS. Early experience of laparoscopic partial nephrectomy for renal tumor. Korean J Urol 27; 4: Jeschke K, Peschel R, Wakonig J, Schellander L, Bartsch G, Henning K. Laparoscopic nephron-sparing surgery for renal tumors. Urology 21;5:-2.. Ficarra V, Novara G, Secco S, Macchi V, Porzionato A, De Caro R, et al. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumors in patients who are candidates for nephron-sparing surgery. Eur Urol 2;Epub ahead of print. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1;13: Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function--measured and estimated glomerular filtration rate. N Engl J Med 2;354: Gill IS, Colombo JR Jr, Moinzadeh A, Finelli A, Ukimura O, Tucker K, et al. Laparoscopic partial nephrectomy in solitary kidney. J Urol 2;175: Ramani AP, Desai MM, Steinberg AP, Ng CS, Abreu SC, Kaouk JH, et al. Complications of laparoscopic partial nephrectomy in 2 cases. J Urol 25;173: Guillonneau B, Bermudez H, Gholami S, El Fettouh H, Gupta R, Adorno Rosa J, et al. Laparoscopic partial nephrectomy for renal tumor: single center experience comparing clamping and no clamping techniques of the renal vasculature. J Urol 23; 1: Desai MM, Gill IS, Ramani AP, Spaliviero M, Rybicki L, Kaouk JH. The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy. BJU Int 25;5: Kobayashi Y, Usui Y, Shima M, Akio H, Miyakita H, Inatsuchi H, et al. Evaluation of renal function after laparoscopic partial nephrectomy with renal scintigraphy using mtechnetium-mercaptoacetyltriglycine. Int J Urol 2;13: Landman J, Rehman J, Sundaram CP, Bhayani S, Monga M, Pattaras JG, et al. Renal hypothermia achieved by retrograde intracavitary saline perfusion. J Endourol 22;1: Janetschek G, Abdelmaksoud A, Bagheri F, Al-Zahrani H, Leeb K, Gschwendtner M. Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion. J Urol 24;171: Venkatesh R, Weld K, Ames CD, Figenshau SR, Sundaram CP, Andriole GL, et al. Laparoscopic partial nephrectomy for renal masses: effect of tumor location. Urology 2;7: Finley DS, Lee DI, Eichel L, Uribe CA, McDougall EM, Clayman RV. Fibrin glue-oxidized cellulose sandwich for laparoscopic wedge resection of small renal lesions. J Urol 25;173: Jeon SS, Kim IY. Laparoscopic partial nephrectomy without hilar control. J Endourol 2;22: Fogarty JD, Hafron JM, Hoenig DM, Ghavamian R. Laparoscopic nephron-sparing surgery for the small exophytic renal mass. JSLS 25;:1-24.

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic