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1 단일기관에서의성인요도하열교정술 10 년경험 Ten-year Experience of Adult Hypospadias Repairs at a Single Center Won Hee Chon, Seong Ik Bang, Sang Don Lee From the Department of Urology, College of Medicine, Pusan National University, Busan, Korea Purpose: We retrospectively evaluated the results and complications of urethroplasty in adult patients with hypospadias. Materials and Methods: Between February 1997 and June 2007, 21 adult patients with hypospadias underwent urethroplasty. The types of hypospadias were as follows: megameatus intact prepuce (MIP; n=4), subcoronal (n=5), distal penile (n=3), midshaft (n=2), penile (n=2), penoscrotal (n=2), and scrotal (n=3). Among the 21 patients, 13 were in the primary operative (group A) and 8 were in the re-operative (group B). Results: The mean age of the patients was 32.4±6.4 years (group A, 33.1±6.0 years; group B, 31.1±7.8 years). The mean duration of catheter drainage was 8.0±2.4 days (group A, 7.9±1.8 days; group B, 8.0±2.1 days). The surgical procedures included tubularized incised plate urethroplasty (n=14), Thiersch-Duplay (n=3), pyramid (n=3), and transverse preputial island flap (n=1). The overall success rate was 61.9% (group A, 92.3%; group B, 12.5%). Urethrocutaneous fistulas and a meatal stricture occurred in 6 and 1 patients, respectively, with both occurring in 1 patient (38.1% overall complication rate). Fistula repairs were performed successfully in 4 patients and another fistula resolved spontaneously. The meatal strictures were treated with simple dilatation. Conclusions: Our data demonstrated a very high success rate in the treatment of primary adult hypospadias. And more careful surgical procedure is needed in patients who had history of previous failure more than 2 times because of significantly high complacation rate. (Korean J Urol 2008;49: ) Key Words: Hypospadias, Adult, Complications 대한비뇨기과학회지제 49 권제 12 호 2008 부산대학교의과대학비뇨기과학교실 천원희ㆍ방성익ㆍ이상돈 접수일자 :2008년 3월 14일채택일자 :2008년 10월 15일 교신저자 : 이상돈부산대학교의과대학비뇨기과학교실부산시서구아미동 1 가 10 번지 TEL: FAX: lsd@pusan.ac.kr 서론요도하열은지역에따른차이를보이기는하나정상출생남아약 300명당 1명의비율로발생하는선천성질환으로알려져있다. 최근요도하열수술은미용적, 기능적으로높은성공률을보여주고있고결손된요도의길이가긴경우를제외하고는대부분한번의수술로완료될수있으며부작용도적다. 1 수술기구의발전, 수술술기의진보, 술후도뇨관의유치및술후상처관리의향상등이이러한수술성적향상의직접적인요인이되어왔다. 2 이전소아요도하열수술의술기및성적에대한많은연구가있었으 나성인요도하열에대한연구는드물었다. 하지만최근들어요도하열수술이성인환자에게미치는정신사회적영향등성인요도하열에관한연구들이보고되고있다. 3-5 이에저자들은본원에서시행한성인요도하열수술에대한치료성적및부작용에대해서조사하였다. 대상및방법 1997년 2월부터 2007년 6월까지본원에서요도하열로수술을시행받은환자중수술당시연령이 20세이상인 21명을대상으로하였다. 수술당시요도하열의유형은요도구의위치에따라 megameatus intact prepuce (MIP) 4례, 관상구 1144

2 천원희외 : 단일기관에서의성인요도하열교정술 10 년경험 1145 부형 5례, 원위부음경부형 3례, 중간음경부형 2례, 근위부음경부형 2례, 음경음낭부형 2례및음낭부형 3례였다. 이전에요도하열수술을한번이라도시행받은적이없는환자 13명을 A군, 시행받은적이있는환자 8명을 B군으로구분하였다. 모든환자에서술후 1개월에환자의자각증상및수술부위를관찰하였고, 이후 3-6개월간격으로추적관찰을권유하였다. 수술부위관찰시요도개구부이외의부위에서요누출이관찰될경우피부요도누공이라판단하였고, 술후요도개구부내경이좁아지면서약뇨를동반할경우요도개구부협착이라판단하였다. B군중 2례 (25.0%) 는이전에 2차례의요도하열수술을시행받았다. 통계분석은 SPSS 12.0K for window 프로그램을사용한 Mann-Whitney U test, Fisher's exact test 및 Mantel-Haenszel chi-square test를이용하였으며 p값이 0.05 미만인경우를통계학적으로유의한것으로판단하였다. 결 환자의연령은평균 32.4±6.4세 (20-45) 였고이전에요도하열수술을시행받지않은군 (A군) 은평균 33.1±6.0세 (20-45), 요도하열수술을시행받은군 (B군) 은평균 31.1± 7.8세 (20-43) 였다 (p=0.296) (Table 1). 요도하열수술에사용된술기는 tubularized incised plate urethroplasty (TIP) 법, Thiersch-Duplay법, pyramid법및 transverse preputial island flap (TPIF) 법이각각 14례 (66.7%), 3례 (14.3%), 3례 (14.3%) 및 1례 (4.7%) 였다 (Table 2). Table 1. Characteristics of patients Total (n=21) Group A (n=13) Group B (n=8) p-value Age (years) 32.4± ± ± * Hospital days (days) 8.9± ± ± * Mean catheter drainage (days) 8.0± ± ± * *: Mann-Whitney U test (group A vs B) 과 술후평균 8.0±2.4일 (6-13) 에도뇨관을제거하였으며 A 군은평균 7.9±1.8일 (6-13), B군은평균 8.0±2.1일 (6-12) 에도뇨관을제거하였다 (p=0.929). 술후 1개월에총 8례 (38.1%) 에서합병증이발생하였고그이후평균 51.2±27.6개월 (6-91) 의추적관찰기간동안새로발생한합병증은없었다. 총 21명의환자중 2명의환자는술후 3개월및 6개월에추적소실되었다. 피부요도누공이 6례 (75.0%), 요도개구부협착이 1례 (12.5%) 였으며요도개구부협착과피부요도누공이동시에발행한경우가 1 례 (12.5%) 였다. A군의경우술후 1례 (7.7%) 에서피부요도누공이발생하였으며 B군은 7례 (87.5%) 에서술후합병증으로피부요도누공, 요도개구부협착및요도개구부협착과피부요도누공이동시에발행한경우가각각 5례 (62.5%), 1 례 (12.5%) 및 1례 (12.5%) 에서발생하였다 (p=0.001). 이전에 2차례요도하열수술을시행받은 2례는모두술후피부요도누공이발생하였다 (Table 3). 요도하열유형을 MIP와관상구부형을원위부로원위부음경부형, 중간음경부형및근위부음경부형을중간부로음경음낭부형과음낭부형을근위부로구분하여합병증을조사하였다. 원위부, 중간부및근위부에서각각 3례 (33.3%), 3례 (42.9%) 및 2례 (40%) 에서합병증이발생하여각부위별로유의한차이를보이지않았다 (p=0.922) (Table 3). 각 Table 2. Surgical methods based on the types of hypospadias Type n TIP Thierschduplay Pyramid TPIF MIP Subcoronal Distal penile Midshaft Proximal penile Penoscrotal Scrotal Total MIP: megameatus intact prepuce, TIP: tubularized incised plate urethroplasty, TPIF: transverse preputial island flap Table 3. Complication rates based on the types of hypospadias in groups A and B Type Total Group A Group B n Complication (%) n Complication (%) n Complication (%) p-value Distal 9 3 (33.3)* 6 1 (16.7) 3 2 (66.7) Middle 7 3 (42.9)* 4 0 (0) 3 3 (100) Proximal 5 2 (40)* 3 0 (0) 2 2 (100) Total 21 8 (38.1) 13 1 (7.7) 8 7 (87.5) *: Mantel-Haenszel chi-square test within three types (p=0.922), : Fisher's exact test (group A vs group B)

3 1146 대한비뇨기과학회지 : 제 49 권제 12 호 2008 Table 4. Complication rates based on the surgical methods in groups A and B Total Group A Group B n Complication (%) n Complication (%) n Complication (%) TIP 14 5 (35.7) (83.3) Non-TIP 7 3 (42.9) 5 1 (20) 2 2 (100) p-value 0.557* 0.385* 0.75* TIP: tubularized incised plate urethroplasty, *: Fisher's exact test (TIP vs Non-TIP) 군에서요도하열유형에따른합병증의발생을비교해보았을때 A군은원위부에서 1례 (16.7%) 의합병증이발생하였고, B군은원위부, 중간부및근위부에서각각 2례 (66.7%), 3례 (100%) 및 2례 (100%) 에서합병증이발생하여중간부에서 A, B군간의유의한차이를보였다 (p=0.029) (Table 3). 수술법에따른합병증은 TIP법인경우 14례중 5례 (35.7%) 에서술후합병증이발생하였으며 TIP법이아닌경우는 7례중 3례 (42.9%) 에서합병증이발생하여두수술법에따른합병증발생은유의한차이를보이지않았다 (p=0.557) (Table 4). 각군에서수술법에따른합병증의발생을비교해보았을때 A군은 TIP법이아닌경우 1례 (20%) 에서합병증이발생하였고, B군은 TIP법과 TIP법이아닌경우각각 5례 (83.3%), 2례 (100%) 에서합병증이발생하여 TIP법에서두군간의유의한차이를보였다 (p=0.003) (Table 4). 술후피부요도누공이발생한 7례중 4례 (57.1%) 는피부요도누공제거술을시행받고치유되었고, 2례 (14.3%) 는추적소실되었으며 1례 (14.3%) 는술후 2개월에자연치유되었다. 술후요도개구부협착을보인 2례는요도부지를이용한요도확장술시행후호전되었으며이후약뇨를보이는환자는없었다. 술후 51.2±27.6개월의경과관찰중전체 21명의환자중추적소실된 2명을제외한 19명 (90.5%) 의환자에서합병증이관찰되지않았다. 고찰요도하열은요도구의위치에따라원위부음경부, 중간음경부, 근위부음경부, 음경음낭부, 음낭부및회음부요도하열로나눌수있으며 MIP는요도하열의한형태로전체요도하열의약 3% 를차지한다. 6 저자들의경우 MIP가 4례 (19.0%) 로높은빈도를보였으며이는다른요도하열에비해상대적으로경한증상과음경피부로덮여있어일상생활에서포경수술전에는미용문제가적어진단과수술이지연되는것으로생각한다. 요도하열교정술은해부학적이상을교정하여궁극적으로정상적배뇨, 성생활의가능, 그리고미용적으로정상적 위치와형태의요도구를가지는것을목표로하며 7 외요도구의위치와크기, 귀두부의상태, 요도판의상태, 음경의형태와크기, 동반되는음경또는음낭의기형, 음경의피부상태및수술자의기호와경험등을고려하여교정술의방법을선택한다. 8 요도하열교정술에는최근까지약 200여가지들의요도성형술과 50여가지의음경만곡교정술이소개되고있으나모든요도하열에적용될수있는최선의방법은없는것으로알려져있다. 9 요도하열교정술로는고전적으로 Thiersch-Duplay법, Mathieu법, King법, Onlay island flap법, meatoplasty and glanuloplasty (MAGPI) 법등이있다. 과거에는요도하열교정수술시섬유성반흔조직인삭대의교정을위해요도판절단이불가피한것으로여겨졌으나 10 Baskin 등 11 과 Erol 등 12 이요도판은섬유성반흔조직이없는풍부한혈류공급과신경분포를가진건강한조직임을보고하였다. 또한 1989년 Rich 등 13 이요도판절개에대한개념을소개한후 1994년 Snodgrass 9 는요도판에깊은종절개를가하여관상화를통하여충분한크기의요도폭을얻는 TIP법을소개하여높은술후성공률을보고하였다. TIP법은요도구의모양이정상요도구와같이수직으로보이게되어미용적으로우수한성적을보이는장점이있다. 14 저자들의경우 14례 (66.7%) 에서 TIP법을시행하여술후 9례에서합병증이발생하지않아 64.3% 의성공률 (group A: 100.0%, group B: 16.7%) 을보였다. MIP의경우다른요도하열과비슷한방법으로수술할경우만족할만한결과를얻지못하는경우가많다. 15 이에 1980년대 Zaontz 16 가 glans approximation procedure (GAP) 법을, Duckett과 Keating 17 이 pyramid법을소개하였고 1990년대 Hill 등 18 이 modified pyramid법을소개하였다. 저자들의경우 4례의 MIP 환자에서 pyramid법을 3례, TIP법을 1례시행하였으며치료성공률은각각 66.7%, 100% 였다. 다양한수술법의개발과술기의발전으로술후합병증이감소되고있지만요도하열수술후에는단순요도피부누공에서부터요도의완전소실까지다양한합병증이발생할수있다. 7 Abu-Arafeh 등 19 은소아요도하열 856례중 72 례 (8.4%) 에서술후합병증이발생하였다고보고하였고,

4 천원희외 : 단일기관에서의성인요도하열교정술 10 년경험 1147 Ghali 등 20 은 544례중술후합병증이 104례 (19.1%) 에서발생하였으며요도하열의정도가심하거나요도판의가로절단이있는경우빈도가높다고보고하였다. 국내연구에의하면 Choi 등 21 은술후약 40.7% 의합병증발생률을보고하였으며 Doo와 Kim 22 은단단계수술에서 40%, 다단계수술에서 48% 의합병증을보고하였다. 국외의보고보다국내보고에서합병증이높은이유로는국외의경우원위부요도하열이많이포함된반면국내의경우근위부요도하열이많이포함되었기때문이라고생각한다. 그리고국내의보고에서 TIP법은 23-46% 의합병증이발생한다고보고되고있다. 23,24 성인요도교정술의경우 Hensle 등 25 이 18세이상의요도하열 42례의연구에서술후 22례 (52.4%) 의합병증을보고하였고 Li 등 26 은 13세이상요도하열환자 113례에서술후 12.4% 의합병증을보고하였다. 국내의연구에서는 Chang과 Kim 27 이 13세이상의 46례의환자에서술후 27 례 (58.7%) 에서합병증이발생하였다고보고하였다. 저자들의경우 8례 (38.1%) 에서합병증이발생하였으나이전에수술을받지않은경우는합병증이단지 1례 (7.7%) 에서발생하였다. 본교실에서시행한소아에서의연구결과에서는처음요도하열수술을시행받은경우전체 206례중 40례 (19.4%) 에서합병증이발생하여성인의 7.7% 에비해더높았으나통계학적으로유의하지는않았다 (p=0.275). 하지만두번이상요도하열수술을시행받은경우전체 39례중 15례 (38.5%) 에서합병증이발생하여성인의 87.5% 에비해낮았다 (p=0.011). 저자들의경우다른연구와같이합병증중피부요도누공이가장흔히발생하였다. 일반적으로성인요도하열의경우소아와는달리높은합병증을보이는데 27 이는성인의경우소아에비해피부및요도판의혈류공급이낮고조직의신선도가떨어지며음모를포함하여수술부위의감염요인이높기때문이라고생각한다. 그래서 Hensle 등 25 도성인요도하열수술후의합병증을감소시키기위해술전모든환자에서요배양검사와적절한항생체치료를시행하고수술시이식편이나피부피판을이용할경우술전음모가없는부위를확인하여음모를가진조직이포함되지않게하여야한다고주장하였다. 저자들의경우수술을 2차례이상시행받은경우 8례중 7례 (87.5%) 에서합병증이발생하여높은빈도를보였다. 이는이전수술로인해피부및요도판의좋지않은상태와혈류공급의저하등에의한것으로생각한다. 하지만대부분의합병증이피부요도누공이나요도개구부협착이었으며, 추적관찰이가능하였던환자에서피부요도누공제거술및요도부지를이용한요도확장술을시행하여모두좋은결과를보였다. 결 성인요도하열의경우요도하열교정술후합병증의발생이소아의경우에비해높으며 2차례이상의요도하열교정술을시행받은경우더높은빈도를보였다. 성인요도하열수술의합병증을줄이기위해특히이전에 2차례이상요도하열수술을시행받았던경우더욱세심한주의가필요하며성인의경우소아에비해협조가용이하므로술후수술부위관리및합병증발생유무의정확한관찰에대한교육이같이이루어져야할것으로생각한다. 아울러성인의경우에도합병증의발생시간단한추가치료를통해좋은결과를기대할수있을것으로생각한다. 론 REFERENCES 1. Sweet RA, Schrott HG, Kurland R, Culp OS. Study of the incidence of hypospadias in Rochester, Minnesota, , and a case-control comparison of possible etiologic factors. Mayo Clin Proc 1974;49: Seo JH, Seo YJ, Chung SK. Surgical correction of hypospadias using tubularized incised plate urethroplasty. Korean J Urol 2002;43: Miller MA, Grant DB. Severe hypospadias with genital ambiguity: adult outcome after staged hypospadias repair. Br J Urol 1997;80: Mureau MA, Slijper FM, Nijman RJ, van der Meulen JC, Verhulst FC, Slob AK. Psychosexual adjustment of children and adolescents after different types of hypospadias surgery: a norm-related study. J Urol 1995;154: Mureau MA, Slijper FM, van der Meulen JC, Verhulst FC, Slob AK. Psychosexual adjustment of men who underwent hypospadias repair: a norm-related study. J Urol 1995;154: Sin SH, Park JS. Glans approximation procedure (GAP) for distal hypospadias repair. Korean J Urol 2003;44: Lee SY, Ryu DS, Oh TH. Tubularized incised-plate urethroplasty: expanded use in primary and repeat surgery for hypospadias. Korean J Urol 2003;44: Duckett JW. Advances in hypospadias repair. Postgrad Med J 1990;66(Suppl 1): Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 1994;151: Devine CJ, Horton CE. Chordee without hypospadias. J Urol 1973;110: Baskin LS, Erol A, Li YW, Liu WH. Anatomy of the neurovascular bundle: is safe mobilization possible? J Urol 2000;164: Erol A, Baskin LS, Li YW, Liu WH. Anatomical studies of the urethral plate: why preservation of the urethral plate is

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar