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1 전남의대학술지제 권제 호 Chonnam Medical Journal Vol., No., pp. 99 DOI:.8/cmj...99 중증신손상환자에대한치료방법의변화및비수술적치료의유용성 전남대학교의과대학비뇨기과학교실 정호석ㆍ김영중ㆍ황의창ㆍ임창민ㆍ김선옥ㆍ오경진ㆍ정승일 * ㆍ강택원ㆍ권동득ㆍ박광성ㆍ류수방 Changes in the Management of High Grade Renal Injury and the Usefulness of Nonoperative Management Ho Suck Chung, Young Jung Kim, Eu Chang Hwang, Chang Min Im, Sun-ouck Kim, Kyung Jin Oh, Seung Il Jung*, Taek Won Kang, Dong Deuk Kwon, Kwangsung Park and Soo Bang Ryu Department of Urology, Chonnam National University Medical School, Gwangju, Korea Despite the increasing incidence of renal trauma, the management of major renal injuries remains controversial. We reviewed our experience to identify changes in renal injury management and to clarify the usefulness of nonsurgical management. We retrospectively analyzed the charts and films of 8 patients admitted to our hospital for renal injury from March 3 to April. We classified the patients into three groups according to treatment methods: conservative treatment, surgical treatment, and percutaneous embolization, and made comparisons between the first (Group A) and last (Group B) patients. Patients were 97 males (7.8%) and 3 females (.%) with a mean age of 3. years. The main cause of injury was related to traffic accidents in cases (8.%), and the most common associated injury was hemoperitoneum in 3 cases (.%). According to radiologic and operative findings, the cases were classified as follows: grade I in cases (.9%), grade II in cases (.%), grade III in 3 cases (8.%), grade IV in 8 cases (37.%), and grade V in cases (.7%). All patients with low grade (grade I, II) and grade V renal injury were treated with conservative therapy and operation, respectively, and there were no differences between Group A and Group B. Grade III and IV renal injury cases showed some difference in management between the two groups, however. In Group B compared with Group A, all grade III renal injury patients were successfully treated with nonoperative management (p=.7). The percutaneous embolization rate was increased (Group A:.%, Group B:.7%), and the surgical treatment rate was decreased (Group A:.%, Group B:.3%) in patients with grade IV renal injuries (p=.3). Nonoperative management was successfully performed even in patients with grade III and IV renal injury; therefore, it will be considered as the first treatment of choice in most high-grade renal injuries except for grade V renal injuries. Key Words: Kidney; Injury; Embolization, Therapeutic 접수일 : 년 월 8 일, 게재결정 : 년 7 월 일 * 교신저자 : 정승일, 9-89, 전남대학교의과대학비뇨기과학교실, Phone: , 779, FAX: , drjsi@yahoo.co.kr 99

2 전남의대학술지제 권제 호 서론신손상은비뇨생식기계에서가장높은빈도를차지하고있는손상으로보통복부외상환자의 % 정도에서발생하는것으로알려져있으며, 최근산업의고도화와자동차의증가및다양한레저스포츠의보급으로인해신손상환자의발생빈도가증가하고있다. 그러나현재까지신손상의치료경험은많았지만신손상환자에서수술적치료를시행해야하는지혹은보존적치료를하여야하는지를결정하는것은매우중요하며, 이에대해서는아직까지다양한의견들이있다. 미국외상수술학회의분류법 에따른신손상등급에근거하여 grade I, II에해당하는경증신손상은보존적치료를하는의견에는이견이없으나, 3 grade III V의중증신손상의경우보존적치료와조기의수술적치료간에논란의대상이되고있다. 그러나최근전산화단층촬영술과같은방사선학적진단술기의발달과외상환자에대한보존적치료기법의향상에힘입어, 이전에는수술적치료를시행하던일부중증신손상에서도비수술적치료가성공적으로이루어졌다는연구결과들이발표되면서, -7 신손상의초기치료로써수술적치료보다는보존적치료가우선적으로시행되는추세에있다. 또한수술적치료를피하면서수술보다는덜침습적인색전술을이용한신손상치료가보고되고있어, 8- 과거의신손상에대한치료방법이보존요법과수술요법으로나뉜다면현재의치료는보존적치료, 중재적방사선치료, 수술적치료로나뉜다고볼수있겠다. 이에따라저자들은최근신손상으로입원하여치료받았던환자들을대상으로신손상환자들의임상적관찰소견, 치료방법에있어서의변화및비수술적치료방법의안정성을확인하여신손상의적절한치료방법을알아보고자하였다. 대상및방법 3년 3월부터 년 월까지신손상으로본원에내원하여입원치료를받았던 8예의환자들을대상으로후향적으로의무기록지및방사선검사소견을분석하여신손상과관련될수있는제반사항을분석하였다. 신손상으로분류한환자는뚜렷한외상병력과신이외의비뇨기계손상이없었던환자들이었고낭종성신질환, 불완전중복요관등 신의해부학적이상등신에선행성질환이있는경우는제외하였다. 신손상의진단은환자의임상증상, 신체검사및방사선학적검사및수술소견으로하였으며방사선학적검사로는복부전산화단층촬영술과선택적으로배설성요로조영술, 혈관조영술, 복부초음파촬영술, 그리고 MRI를시행하였다. 신손상의정도는미국외상수술학회 (American Association for the Surgery of Trauma) 의장기손상등급위원회 (Organ Injury Scaling Committee) 에의한등급 에따라분류하였다. 8예의환자들은 명을기준으로 Group A (3년 3 월부터 년 월 ), Group B (년 7월부터 년 월 ) 로나누었으며치료방법에따라보존적치료, 중재적방사선치료, 수술적치료군으로분류하여비교분석하였다. 보존적치료를환자들의경우에는지속적인혈역동학적인상태의평가, 주기적인혈색소의측정과함께예방적인항생제사용과육안적혈뇨가해소될때까지의침상안정을시행하였다. 모든환자는연령및성별분포, 외상의원인, 신손상의정도, 응급실에서의활력징후평가및혈색소, 혈중크레아티닌, 육안적및현미경적혈뇨의유무를포함한임상증상과신체검사, 방사선학적소견, 동반손상장기수와상태등을분석하고수혈량, 중환자실입원기간, 입원기간, 합병증, 사망률등을조사하였고손상 주후에추적검사로복부전산화단층촬영술을시행하였다. 통계처리는 Pearson Chi-Square test를이용하였고 p값이. 미만일때통계학적으로유의한것으로판정하였다. 결과. 연령및성별분포환자의나이는 세미만 예 (.9%), 대 9예 (.7%), 대 예 (.9%), 3대 예 (.9%), 대 예 (.%), 대 예 (7.8%), 대이상 예 (.3%) 로 세에서 9세까지분포하였으며평균연령은 3.세였다. 8 명의환자중남자는 97명 (7.8%), 여자는 3명 (.%) 으로사회적활동이활발한남자에서더많음을알수있었다 (Table ).. 손상정도및원인신손상의정도 는 grade I 3예 (.%), grade II 예

3 정호석외 인 : 중증신손상환자에대한치료방법의변화및비수술적치료의유용성 (.%), grade III 3예 (8.%), grade IV 8예 (37.%), grade V 예 (.7%) 였으며 grade III-V의중증신손상이 99예 (77.3%) 로경증신손상 9예 (.%) 보다많았다. 신손상원인은교통사고가 예 (8.%) 로가장많았으며, 폭행및운동중손상 예 (.8%), 미끄러짐 예 (.%), 추락 7예 (3.3%), 자상 예 (3.%) 순의빈도를보였다 (Table ). 3. 치료전체 8예의신손상환자에서보존적치료는 9예 (73.%), 중재적방사선치료는 예 (9.%), 수술적치료는 예 (7.%) 였다. 이중경증신손상으로진단된 9예 (.%) 는모두보존요법으로치료하여특별한합병증없이완치되었다 (Table 3). 중증신손상인 grade III-V 환자의경우, grade III (3예) 는보전적치료 3예 (83.3%), 중재적방사선치료 예 (.%), 수술적치료 예 (.%) 였으며, grade IV (8예) 는보존적치료 3예 (7.9%), 중재적방사선치료 8예 (.7%), 수술적치료 예 (.%) 였고, grade V (예) 의신손상환자는모두수술적치료를시행하였다. 수술적치료를시행한 예모두에서내원 시간이내에수술이시행되었으며, 8예에서는심한복강내장기손상의동반으로일반외과에서먼저개복후 차적으로신손상에대한수술이시행되었고, 예에서는동반손상 ( 비장및췌장손상 ) 에의한원인으로사망하였다. Table. Age and sex distribution between Group A and Group B Group A Group B Age/Sex (%) Male Female Male Female 명을기준으로전후를비교한결과, grade I, II 는모두보존적치료를, grade V는모두수술적치료를시행하여 Group A, B 사이에치료방법의변화는없었다. 반면, Group A와비교한경우, Group B에서 grade III 환자는비수술적방법 ( 보존적치료 7예, 중재적방사선치료 예 ) 만으로도치료가가능하게되었으며 (p=.7), grade IV에서는중재적방사선치료는 3예 (.%) 에서 예 (.7%) 로증가, 수술적치료가 예 (%) 에서 예 (.3%) 로감소하여비수술적방법의비중이증가하여 (p=.3), 두군간에통계적으로는유의한차이를보이지는않았으나시간이지남에따라 grade III, IV 신손상환자에서수술적치료는감소하는경향을보였다 (Table ). Table. Classification and cause of injury between Group A and Group B Grade I II III IV V Cause Traffic accident Fall down Slip down Other blunt trauma Stab injury Group A Group B (%) (.) (.) 3 (8.) 8 (37.) (.7) (8.) 7 (3.3) (.) (.8) (3.) 8 < (.9) 9 (.7) (.9) (.9) (.) (7.8) (.3) 8 Table 3. Comparison of treatment between Group A and Group B Treatment Group A Group B (%) Conservative Angioembolization Nephrectomy 9 (73.) (9.) (7.) 8 Table. Comparison of treatment between classification (Grade III, IV, V) in Group A and Group B Treatment Group A Group B Gr III Gr IV Gr V (%) Gr III Gr IV Gr V (%) Conservative Angioembolization Nephrectomy (8.) (.3) (3.) (73.8) (3.) (3.)

4 전남의대학술지제 권제 호. 동반된타장기손상 신손상환자중타장기손상이동반된경우는 8예 (8.3%) 였으며, 개이상의손상이동반된경우는 3예였다. 동반손상부위로는혈복이 3예 (.%) 로가장많았으며, 사지골절 7예, 기혈흉 예, 늑골골절 예, 간손상 예, 골반골절 예, 비장손상 9예, 두부손상 예순이었다 (Table ). Table. Comparison of associated extrarenal injuries Associated injuries No. of patients (%) Hemoperitoneum Fracture of extremities Hemopneumothorax Rib fracture Liver injury Pelvic fracture Spleen injury Head injury 고 신손상치료의궁극적인목표는환자의생명을구하며가능한한신조직을최대한보존하고합병증을최소화할수있도록하여야한다. 신손상은손상의정도, 동반손상여부, 환자의상태및의사의치료경험등에따라치료방법이달라질수있으며, 최근혈관조영술후동맥혈관색전술을 찰 3 (.) 7 (.) (.) (.) (.) (7.8) 9 (7.) (3.9) 3 () 시행하여성공적으로치료한경우가보고되고있어, 8- 과거의신손상에대한치료방법이보존적혹은수술적치료로만나뉜다면현재의치료는보존적치료, 응급중재적방사선치료, 수술적치료로구분할수있다. 이에본연구는최근 7 년간의 8예신손상환자들을비교분석함으로써환자들의특성및치료방법에있어서의변화를분석하고비수술적치료방법의유용성과안정성을평가함으로써현재까지이견이있는중증신손상환자들에대한치료원칙을정하고자하는데의의가있겠다. 저자들의경우, 환자의나이는 세에서 9세까지다양하게분포하고있으며특징적으로 대이상의고령에서 예 (.3%) 로높은비중을차지하였는데이는 3차의료기관의특성상대부분의환자는타병원에서전원된경우로기저질환및타기관의손상이동반된경우가대부분이었다. 또한 3예 (3.%) 의소아신손상환자들도전원되어내원하였으며, 성인과는다른소아의해부학적구조와임상적특성 3- 에따라진단및치료과정의어려움때문이었다. 손상의기전은신손상의정도및수술의필요성, 그리고동반손상여부등에대한중요한예측인자이다., 저자들의경우도유사한결과를보였는데 (Table, ), 신손상을일으키는가장큰원인은복부둔상으로 8-9% 를차지하고있으며, 복부둔상을일으키는원인으로는교통사고, 추락사고, 상해및운동중손상등이있고, 이중교통사고가가장많은원인을차지하였다. 7-9 소아의경우에는추락사고가 % 로가장많고그다음이교통사고인것으로보고하고있다. 3,,9 신손상을일으키는원인중둔상을제외한나머지는총상혹은자상등의관통상에의한다. 관통상은크게총상과자상으로구별되며이중총상이 % 정도를 Fig.. Comparison of treatment between classification (Grade III, IV) in Group A and Group B (%). *All patients with grade V renal injury were treated with nephrectomy, and it showed no difference between two groups.

5 정호석외 인 : 중증신손상환자에대한치료방법의변화및비수술적치료의유용성 3 차지하는미국과는달리 우리나라에서는대부분자상에의한것으로보고되고있다. 자상의위치가측복부나배부일경우복부나흉부에비해신손상의빈도는현저히증가하며., 국내에서보고된연구결과에의하면복부자상에서신손상의빈도는약 % 정도인것으로알려져있다. 배설성요로조영술, 혈관조영술, 복부초음파촬영술등은전산화단층촬영술이도입되기이전에는신손상의진단에많이이용되었으나, 전산화단층촬영술이신손상의진단에사용되면서부터상대적인진단적정확성및침습성을이유로초기검사로널리시행되고있지않다. 전산화단층촬영술은비교적쉽고빠르게시행할수있으며, 3차원적인영상을제공함으로써신손상을정확하게진단할수있게해준다. 피막하혈종의존재뿐만아니라신실질열상의깊이, 요누출, 비활성조직의정도, 신혈관손상, 복부내동반손상의유무등을알수있다.,9, 이러한전산화단층촬영술의진단적정확성은많은중증신손상환자들에서안전한비수술적치료를가능하게하였다. 그러나신정맥손상이의심되거나전산화단층촬영술에서확실치않은신동맥손상이의심될때에는혈관조영술을시행하게되며, 최근에는출혈이지속되는신손상환자에서수술적치료를대신한치료로동맥혈관색전술 (arterial embolization) 을시행하기위해혈관조영술을시행하는추세이다. 3, 이러한방사선학적진단술기의발달과외상환자에대한보존적치료기법의향상에힘입어, 이전에는수술적치료를시행하던일부중증신손상에서도비수술적치료가성공적으로이루어졌다는연구결과들이발표되면서, -7 신손상의초기치료로써수술적치료보다는보존적치료가우선적으로시행되는추세에있다. 그러나 grade III-V의중증신손상인경우보존적요법과조기의수술적요법간에아직까지논란의대상이되고있다. Peters와 Bright 는보존적치료후지연수술의빈도를.% 로보고했고보존적요법이조기의수술적치료보다재원기간이길었다고주장하였으며, Husmann과 Morris 는중증신둔상에서허혈관성신절편을가진경우 9% 의합병증발생률을보고하여조기수술적요법의필요성을주장하였다. 이에반하여, Moudouni 등 7 은중증신손상환자에서도보존적치료중에발생하는이환률은예상보다낮아대부분의둔상성신손상은비수술적치료로도가능하다고하였으며, Danuser 등 8 도수술적치료와보존적치료의결과를비교하여, 초기에수술적치료를시행한군에서수혈량과신실질의소실률이더높다고보고함으로써중증신손상에서도보존적치료의효용성을강조하였 다. 또한 Buckley와 McAninch 9 는 grade IV 신손상의경우에도혈류역학적으로안정된환자라면보존적치료로완치가가능할뿐만아니라, 수술적치료를시행한군과비교하였을때입원기간및신기능의보존율에도차이가없다고함으로써보존적치료의안정성을확인하였다. 본연구에서도 grade III, IV에서신손상환자의치료방법의변화는통계학적인의의를보이지는못하였으나, Group B에서 Group A와비교하여비수술적인방법으로성공적으로치료되었음을확인하였다 (Table ). 그러나 grade V 신손상의경우, McAninch 3 는다발성신열상의개념에저자들마다일치된견해가형성되지않아주관적으로해석되고있으며 Altman 등 7 이보존적치료를시행한 grade V의다발성신열상으로분류한환자들중대부분은 grade IV로분류되어야한다고지적하면서, 다수의심한열상과심한출혈을동반한경우에만 grade V로분류되어야하며이런경우에는신적출술이반드시필요하다고주장하였다. 저자들도최근의이러한관점에서 grade V를신실질의열상이다발적으로발생하여혈역학적으로불안정한환자로정의하고모두수술적인치료를시행하였으며 Group 간에치료방법의변화는없었다 (Table ). 본연구는후향적인연구에따른한계점으로신손상환자의치료결정을내리는의사에따라환자들의치료방법을선택함에있어서기준을달리할수있다는것, Group A와 B 환자군에서 grade V의경우에서와같이일부비교대상환자수가달라정확한비교분석이어려울수있다는것, 그리고대부분의환자들이안정적인임상증상과추적검사상에서특이소견을보이지않을경우타병원으로전원되어모든환자들에대하여추적관찰을시행하지는못하여고혈압, 감염등의신손상합병증에대한확인이불가능하였던것으로이를극복하기위해서는전향적다기관의대규모연구가필요하리라생각된다. 최근방사선적검사방법의발달과외상환자관리기법의향상으로중증신손상환자에서도중재적방사선시술또는보존적요법으로치료가가능하게되었다. 혈류역학적으로불안정하거나복강내장기손상이동반된경우를제외하고는중증신손상에서도손상기전에상관없이중재적방사선시술또는보존적요법이영역을확대되고있으며, 보존적치료중합병증이발생하더라도환자상태에대한정확한평가와내비뇨기과적인처치등의조치가신속하게이루어진다면합병증및이환율없이신보존율을높일수있을것으로생각된다. 그러나비뇨기과적수술이최근복강경또는

6 전남의대학술지제 권제 호 로봇에의한비침습적수술방법으로시행됨에따라개복수술에대한경험이자칫줄어들수있는현실에서신손상에대한수술적치료는지속적으로시행되고있어신손상에대한개복수술에대한술기를익혀신손상환자의치료에임해야할것이다. References. Nash PA, Carroll PR. Staging of renal trauma. In: Mc-Aninch JW, ed. Traumatic and reconstructive urology. st ed. Philadelphia: Saunders, 99;9-.. Moore EE, Shackford S, Pachter HL, McAninch JW, Browner BD, Champion HR, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma 989;9:-. 3. Guerriero WG. Renal trauma. In: Guerriero WG, Devin CJ Jr, eds. Urological injuries. st ed. Norwalk: Appleton Century Crofts, 98;9-.. Cass AS, Luxenberg M. Conservative or immediate surgical management of blunt renal injuries. J Urol 983;3:-.. Smith EM, Elder JS, Spirnak JP. Major blunt renal trauma in the pediatric population: is a nonoperative approach indicated? J Urol 993;9:-8.. Buckley JC, McAninch JW. Selective management of isolated and nonisolated grade IV renal injuries. J Urol ;7: Altman AL, Haas C, Dinchman KH, Spirnak JP. Selective nonoperative management of blunt grade renal injury. J Urol ;: Sofocleous CT, Hinrichs C, Hubbi B, Brountzos E, Kaul S, Kannarkat G, et al. Angiographic findings and embolotherapy in renal arterial trauma. Cardiovasc Intervent Radiol ;8: Lee JY, Cass AS. Renal injuries in children. In: McAninch JW, ed. Traumatic and reconstructive urology. st ed. Philadelphia: Saunders, 99; Khan AB, Reid AW. Management of renal stab wounds by arteriographic embolisation. Scand J Urol Nephrol 99;8:9-.. Beaujeux R, Saussine C, al-fakir A, Boudjema K, Roy C, Jacqmin D, et al. Superselective endo-vascular treatment of renal vascular lesions. J Urol 99;3:-7.. McAninch JW, Carroll PR, Klosterman PW, Dixon CM, Greenblatt MN. Renal reconstruction after injury. J Urol 99;: Kim HG, Kim SJ, Kim KM, Choi H. Kidney injury in children. Korean J Urol 99;33:38-.. Boone TB, Gilling PJ, Husmann DA. Ureteropelvic junction disruption following blunt abdominal trauma. J Urol 993;:33-.. Buckley JC, McAninch JW. The diagnosis, management, and outcomes of pediatric renal injuries. Urol Clin North Am ;33:33-.. McAninch JW, Santucci RA. Renal and ureteral trauma. In:Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell- Walsh urology. 9th ed. Philadelphia: Saunders, 7; Wessells H. Evaluation and management of renal trauma in the st century. AUA Update Ser ;:3-9.. Mee SL, McAninch JW, Robinson AL, Auerbach PS, Carroll PR. Radiographic assessment of renal trauma: a -year prospective study of patient selection. J Urol 989;: Herschorn S, Radomski SB, Shoskes DA, Mahoney J, Hirshberg E, Klotz L. Evaluation and treatment of blunt renal trauma. J Urol 99;:7-7.. Eastham JA, Wilson TG, Ahlering TE. Urological evaluation and management of renal proximity stab wounds. J Urol 993;: Bernath AS, Schutte H, Fernandez RR, Addonizio JC. Stab wounds of the kidney: conservative management in flank penetration. J Urol 983;9:8-7.. Kyoun JK, Cho SY, Lee JB. Renal trauma in abdominal and thoracic stab injury: comparison of incidence and degree of injury according to the stab entrance site. Korean J Urol 3;: Fisher RG, Ben-Menachem Y, Whigham C. Stab wounds of the renal artery branches: angiographic diagnosis and treatment by embolizatin. AJR Am J Roentgenol 989;:3-.. Alsikafi NF, Rosenstein DI. Staging, evaluation, and nonoperative management of renal injuries. Urol Clin North Am ;33:3-9.. Peters PC, Bright TC 3rd. Blunt renal injuries. Urol Clin North Am 977;:7-8.. Husmann DA, Morris JS. Attempted nonoperative management of blunt renal lacerations extending through the corticomedullary junction: the short-term and long-term sequelae. J Urol 99;3: Moudouni SM, Patard JJ, Manunta A, Guiraud P, Guille F, Lobel B. A conservative approach to major blunt renal lacerations with urinary extravasation and devitalized renal segments. BJU Int ;87: Danuser H, Wille S, Zöscher G, Studer U. How to treat blunt kidney ruptures: primary open surgery or conservative treatment with deferred surgery when necessary? Eur Urol ;39: Buckley JC, McAninch JW. Selective management of isolated and nonisolated grade IV renal injuries. J Urol ;7: McAninch JW. Selective nonoperative management of blunt grade renal injury (Ed. comment). J Urol ;:3-.

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untitled 증례보고 응급중재적방사선시술로치유된현성출혈이있는신손상치험 Renal Ruptures with Active Bleeding Treated with Emergency Selective Renal Arterial Embolization Hyun Ho Hwang, Sang Hyeon Cheon, Kyung Hyun Moon, Seung Kyu Lee, Hyun Soo