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1 신경탓방광환자에서의회장을이용한 Goodwin 형방광확대술의임상경험 Long-term Follow up of Augmentation Ileocystoplasty with Goodwin's Ileal Cup Patched Bladder Joo Hyoung Lee, Cheol Young Oh, Sang Yol Mah From the Department of Urology, Yongdong Severance Hospital, Yonsei University Health System, Seoul, Korea Purpose: We evaluated the long-term outcomes in patients undergoing augmentation ileocystoplasty with Goodwin s ileal cup patched bladder. Materials and Methods: This was a retrospective study of 72 consecutive patients who underwent augmentation ileocystoplasty because of decreased bladder capacity, vesico-ureteral reflux and urinary incontinence. The outcomes assessed included the continence status, bladder capacity, upper tract status, and significant post-operative complications. Results: The 72 patients studied (61 men and 11 women) were 12 to 62 years old (mean age 35.6). The follow up was 0.3 to 7.9 years (mean 5.4). The preoperative diagnoses were a neurogenic bladder from spinal cord injury in 54 patients, meningomyelocele in 5, pelvic trauma in 3, polymyelitis in 2, GU tuberculosis in 2, cerebrovascular diseases in 2, and disc rupture in 2. The bladder capacity was significantly increased from 168cc to 392cc postoperatively and the maximal bladder capacity was increased along with the decreased number of daily clean intermittent catheterizations. The most common complication related to surgery was a paralytic ileus. While most cases of unilateral reflux disappeared, bilateral or high grade reflux remained during the postoperative follow up period. Conclusions: Bladder augmentation provided durable clinical and urodynamic improvement for patients with neurogenic and contracted bladders. (Korean J Urol 2008;49: ) Key Words: Urinary bladder, Neurogenic, Treatment 대한비뇨기과학회지제 49 권제 7 호 2008 연세대학교의과대학비뇨기과학교실 이주형ㆍ오철영ㆍ마상열 접수일자 :2008년 4월 7일채택일자 :2008년 5월 19일 교신저자 : 마상열연세대학교영동세브란스병원비뇨기과서울시강남구도곡동 TEL: FAX: mahsy@yuhs.ac 서론방광의해부학적혹은기능적용적이감소하게되면높은방광내압과낮은유순도, 배뇨근과다반사혹은배뇨근- 조임근협동장애 (detrusor-external sphincter dyssynergia; DESD) 등을유발하여비가역적인상부요로손상을초래하게되며요실금과요로감염등의합병증의발현이높아지게된다. 이런환자들의우선적인치료방법으로는간헐적인도뇨법과방광이완제를포함한약물치료를선택하게되지만, 이런치료법들이실패할경우수술적인치료를고려하게되는데, 영구적요도조임근절개술이나치골위방광창냄술, 방광확대술등이수술적치료법으로임상에서시행되 고있다. 1,2 하지만요도조임근절개술이나치골위방광창냄술등은영구적인요실금을유발하거나도뇨관의지속적인유치등의단점을가지고있어서, 방광확대술을통한수술적치료가요자제능력의획득과방광용적확대및낮은방광내압유지라는생리학적인측면뿐아니라환자의삶의질측면에서도여러장점을가지고있다. 방광확대술은 1889년 von Mikulicz 등 1 이처음으로사람에게회장관을이용한방광확대술을발표한이후에여러종류의위장관을이용한술식이소개되고이에대한장기치료성적과이에따른문제점을보완하고자연구들이진행되어왔다. 2-5 이후에는위장관을이용한방광확대술이외에도방광벽으로부터근육층만을제거하는자가방광확대술이나늘어난요관을이용하여방광확대술을시행하는방법등이고안되어 598

2 이주형외 :Goodwin 형방광확대술시술의임상경험 599 위장관을이용한방광확대술의단점을보완하고자하는노력들도병행하고있다. 6-8 본연구에서는척수손상이나외상등에의한높은방광내압, 방광유순도감소및위축방광과같은소견을보이는환자에서 1959년 Goodwin 등 9 이처음발표한 Goodwin 형회장방광 (Goodwin's ileal cup-patched bladder) 을이용한방광확대술의장기추적관찰의결과를통해서방광확대술의임상적유용성에대해서보고하고자한다. 대상및방법 1999년 7월부터 2007년 3월까지신경탓방광에따른방광내압의상승과이로인한상부요로의손상, 요실금과너무잦은자가도뇨의빈도등의배뇨증상, 재발성요로감염, 심하게감소된방광용적등의임상소견을보여회장을이용한 Goodwin형방광확대술을시행받은환자중에서장기추적관찰이가능한 72명의환자를대상으로하였다. 대상환자들은술전적절한내과적치료혹은보존적인치료에도불구하고요실금이나재발성요로감염, 상부요로의손상등과같은합병증이지속되는경우로서각각의환자의임상상태에따라수술적치료를선택하였다. 모든환자들은병력및신체검사, 수술에필요한기본검사이외에도방광기능및상부요로기능의평가를위해요검사및요배양검사, 혈중 blood urea nitrogen (BUN) 과크레아티닌수치, 배뇨요도방광조영술 (voiding cystourethrography; VCUG), 정맥신우조영술, 요역동학검사, 신장초음파촬영술등을시행하였다. 수술전후의기능적방광용적의변화와방광요관역류의지속여부등의판정을위해필요한경우술후배뇨요도방광조영술및요역동학검사등을시행하였으며, 외래추적관찰기간에혈중 BUN과크레아티닌치, 전해질검사및신장초음파촬영술등을통해신기능및체내전해질불균형에대한평가를시행하였다. 방광용적에대한평가는수술전후에시행한요역동학검사에서의최대방광용적혹은배뇨일지를통해분석하였으며요실금은하루에사용하는패드의양을통해호전여부를판정하였다. 수술방법은 Goodwin 등 9 이고안한 Ileal-cup patched bladder 의방법을사용하였다. 우선회맹부의근위부에서 15cm 이상의장분절을보존한후에 30-40cm의회장절을유리시킨다. 유리된회장절을장간막반대쪽의경계면을따라종 (longitudinal) 절개를한후절개면내측과외측의순차적인봉합을통해 U자형의회장주머니를만든다. 이렇게만들어진회장주머니를기존의방광의절개면을따라끝끝연결 (end-to-end anastomosis) 을한다 (Fig. 1). 환자에따 Fig. 1. The flat patch of the ileum formed is pulled together in the form of a U shape and sutured together with a continuous, intermittently locking catgut sutures. After the peritoneum has been mobilized from the base of the bladder, the bladder is opened in the midline, through its vertex. The ileac patch is then sewed to the bladder beginning posterior in the midline and working laterally from each side using a continuous catgut sutures. 라서는방광요관역류교정을위한항역류수술을함께시행하였는데, 항역류술식은 Lich-Gregoir 술식을사용하였다. 수술을마치기전에기존의방광에치골위방광창냄술을시행한후 20Fr silicone 도뇨관을유치하였으며, 요도에도같은크기의도뇨관을유치하였다. 요도도뇨관은술후 7-10 일에제거하였고치골위방광창냄술시행후삽입한도뇨관은 14일이후에환자임상경과에따라서제거시기를결정하였다. 결 환자의수술당시평균연령은 35.6세 (12-62) 였으며평균추적관찰기간은 5.4년 ( ) 이었다. 대상환자의성별은남성 61명 (84.7%), 여성 11명 (15.3%) 으로남성환자가더많았다. 신경탓방광환자의원인질환으로는척수손상에의한신경탓방광환자가가장많은 54명 (75%) 을차지했고척수수막류와뇌혈관질환이각각 5명 (6.9%), 골반외상 3명 (4.2%) 이었으며, 이외에도회백수염, 추간판파열, 결핵에의한 2차변성등의환자들이각각 2명 (2.8%) 으로나타났다 (Table 1). 수술전합병증으로는요실금이가장흔했고 (57명, 79.2%) 재발성요로감염 (34명, 47.2%) 이나청결자가도뇨의횟수의증가 (46명, 63.9%) 등도흔한합병증으로보고되었다. 특히목뼈손상환자의경우에청결자가도뇨사이에방광의팽창으로인한자율신경반사부전 (autonomic dysreflexia) 이수술을시행하게되는중요한이유중의하나로나타났다. 신경탓방광과동반된방광요관역류를보인환자는모두 과

3 600 대한비뇨기과학회지 : 제 49 권제 7 호 2008 Table 1. Clinical characteristics of the patients Clinical characteristics No. of patients(%) No. of patients 72 Mean age (years) 35.6 (12-62) Male/female 61 (84.7)/11 (15.3) Cause Myelomeningocele 5 (6.9) Spinal cord injury 54 (75) Cervical spine 14 (19.4) Thoracic spine 28 (38.9) Lumbar spine 12 (16.7) Pelvic trauma 3 (4.2) Poliomyelitis 2 (2.8) Rupture of intervertebral disc 2 (2.8) Tuberculosis 2 (2.8) Cerebrovascular disease 5 (6.9) Table 2. Preoperative complication and vesicoureteral reflux Preoperative complication & vesicoureteral reflux No. of patients (%) Preoperative complication (multiple) Urianry incontinence 57 (79.2) Increased times of CIC 46 (63.9) Recurrent urinary tract infection 34 (47.2) Autonomic dysreflexia 11 (15.3) Preoperative vesicoureteral reflux Bilateral 45 (62.5) Unilateral 17 (23.6) Anti-reflux surgery Bilateral 6 (8.3) Unilateral 8 (11.1) Concurrent artificial sphincter implantation 3 (4.1) due to internal sphincter deficiency (AMS 800 AUS) CIC: clean intermittent catheterization, AUS: artificial urinary sphincter 62명 (86.1%) 으로이중에서 45명의환자는한쪽의방광요관역류를, 17명의환자는양쪽의역류소견을보였다. Grade 3 이상의고등급의한쪽방광요관역류를보이는 8명의환자와양쪽의역류를보인환자들중에서역류가심한 6명의환자는방광확대술과더불어항역류수술을함께시행받았으며, 대상환자들중 3명의환자는내인성요도기능부전이동반되어인공요도조임근수술을함께시행하였다. 대상환자중 2명은무기능콩팥에대해한쪽콩팥절제술을동시에시행하였다 (Table 2). 수술후모든대상환자들은청결자가도뇨법을통해배뇨를하였는데, 술전일일평균 9.3회이던도뇨횟수는수술후 6.1회로의미있게감소하였다. 모든대상환자들은퇴원 Table 3. Surgical outcomes Mean times of CIC Preoperative 9.3 times/day Postoperative 6.1 times/day Vesicoureteral reflux Unilateral 45 Anti-relflux surgery was done 1/3 Anti-relflux surgery was not done 7/42 Bilateral 17 Anti-relflux surgery was done 4/8 (bilateral 3, unilateral 1) Anti-relflux surgery was not done 11/11 (bilateral 10, unilateral 1) Mean bladder capacity Preoperative 168cc Postoperative (2 months) 392cc Postoperative (12 months or more) 453cc Mean vesical pressure Preoperative 55cmH 2O Postoperative (2 months) 21.5cmH 2O Postoperative (12 months or more) 20.7cmH 2O CIC: clean intermittent catheterization Table 4. Postoperative complications Postoperative complications No. of patients (%) Paralytic ileus 18 (25) Experience of obstruction due to mucous secretion 12 (16.7) Febrile urinary tract infection 7 (9.7) Urinary leaking at anastomosis site 6 (8.3) Electrolyte imbalance 4 (5.6) Sepsis 2 (2.8) 후 2개월에요역동학검사를시행하였으며, 필요한경우에술후 1년이경과한시점에요역동학검사를선별적으로시행하였다. 술후 2개월에시행한요역동학검사를통해평가한평균방광용적과방광내압은 392cc와 21.5cmH 2O로서수술전 168cc와 55cmH 2O의수치와비교할때요역동학검사수치에서뚜렷한호전을보임을알수있었다. 총 72명의환자들중 43명의환자들은수술후 1년혹은그이상이지난시점에서시행한요역동학검사의결과에대한평가가가능했는데, 평균방광용적 453cc, 평균방광내압은 20.7cmH 2O로나타났으며, 수술후 2개월에시행한요역동학검사와큰차이를보이지않았다. 한쪽의방광요관역류가있던환자들중항역류수술을시행받은 8명의환자중에서수술후에역류가지속적으로남아있던환자는 2명이었으며, 항역류술식을시행받지않고방광확대술만을시행받은나머지 37명의환자들중 5명에서수술후에도역

4 이주형외 :Goodwin 형방광확대술시술의임상경험 601 류가관찰되었다. 양쪽방광요관역류를보였던 17명중항역류술식을받지않고방광확대술만시행한 11명의환자는술후시행한배뇨중요도방광조영술에서역류가소실되지않고양측으로역류가지속되었으며, 항역류수술을받은 6명의환자들중 2명은양쪽의역류가, 1명은한쪽의역류가지속되는것으로나타났다 (Table 3). 수술과관련된가장흔한합병증으로는마비성장폐색증이 18명 (25%) 으로가장흔했으나, 모두보존적인치료만으로호전되었으며, 연결부위요누출 (6명, 8.3%), 열성요로감염 (7명, 9.7%) 등도흔한합병증으로보고되었다 (Table 4). 고찰방광의용적과순응도의감소는요저장과요배출이라는가장기본적인방광기능의이상을넘어서이차적으로상부요로의손상을가져오게되어결국신기능의악화를초래할수있는심각한문제이다. 대부분의방광의과반사, 적은방광용적, 높은방광내압등의치료에있어서초기접근은항콜린성약제와같은약물요법과더불어청결간헐도뇨법등을통한보존적치료를선택한다. 이런보존적인치료법이실패할경우선택할수있는것이바로수술적치료법인데, 방광확대술은현재이런환자들의수술적치료법의표준이라는데에많은연구자들이동의한다. 1,2,10 방광확대술을통해얻고자하는궁극적인목표는충만기에낮은방광내압을유지하면서방광용적을생리적인수준까지높이며요관의폐색이나역류없이상부요로의손상을방지하고요자제능을회복하여요실금을방지하는것으로크게정리할수있는데 이러한방광의생리적인기능의회복에최대한가까운치료성적을얻기위한다양한술기들이지금도많은연구자들에의해제안되고있다. 저자들은모든대상환자들에게회장을이용한 Goodwin 형회장방광을이용하여방광확대술을시행하였는데, 방광확대술을위해위장관중어느부위가가장적합한지에대해서는여전히연구자들사이에서논란이있으며, 각각의임상적용에있어장단점이모두존재한다. 저자들과같이회장을이용하는경우시술하기가쉽고유순도가좋으며점액의생성이상대적으로적은장점을가지고있어가장많이사용되지만, 만성설사나비타민 B12의결핍증, 대사산증의발현가능성등의제한점을동시에가지고있다. 14,15 저자들은이번연구를통해방광확대술시행후에방광용적의증가와방광내압의감소에있어서만족할만한치료효과를확인할수있었다. 특히최대방광내압의감소는상부요로의손상과관련된중요한인자로서방광확대술을 통해상부요로의진행성손상의위험을감소시킬수있다는객관적근거가되므로그의의가크다. 이와같은요역동학검사의호전정도는 Blaivas 등 2 의 572cc와 Kim 등 10 의 510cc와비교할때방광용적은다소작지만생리적인방광용적을고려할때임상적으로큰차이를부여할수없으며, 더불어방광내압의감소에있어서는동등한결과를보이고있는점등을고려할때만족할만한결과이다. 이와같은수술전후의요역동학검사수치의변화는장기적으로방광확대술의치료성적에가장밀접한관련을가지고있으며, 방광확대술의임상적유용성을객관적으로판단할수있는근거와추적관찰기간에유용한지표로사용될수있어서임상적으로의미가크다. 16 방광확대술을통해얻고자하는중요한목표중의하나가바로방광요관역류의호전또는소실이다. 술전에방광요관역류가확인된환자에게있어서항역류수술의필요성에대해서는여전히논란이있다. Simforoosh 등 17 은추가적인항역류수술없이방광확대술단독만으로도대상환자의 85.4% (111명/130명) 에서역류의소실을, 10.8% (14명/130명) 에서호전을보인다고보고하면서추가적인항역류수술의유용성에의문을제기하였다. 반면 Hayashi 등 18 은고등급의방광요관역류의경우에는방광확대술과더불어항역류수술을시행하는것이역류의소실과호전에도움을준다고도하였다. 본연구에서도한쪽의방광요관역류의경우추가적인항역류수술을시행하지않고도많은수에서역류가소실되었음을확인할수있었다 (86.5%, 32명 /37명). 반면양쪽의방광요관역류가있던환자중에서항역류술식없이방광확대술만시행한 11명의경우수술후에방광요관역류가소실되지않고지속되었으며, 술전고등급의방광요관역류를보여서항역류수술을시행받은환자중일부는수술후에도방광요관역류가소실되지않고남아있기도하였다. 이와같은결과를토대로저자들은한쪽의저등급의방광요관역류는추가적인항역류수술없이도역류의소실혹은호전을기대할수있으나, 양측성또는고등급의방광요관역류의경우에는환자에따라서추가적인항역류수술을고려해야한다고생각한다. 다만수술후에역류가남아있는환자들도방광확대술시행후에는술전에비해서요로감염의빈도가줄고, 상부요로의손상이감소하는것으로보아역류의존재만으로방광확대술의치료효과자체에결정적인영향을준다고결론내리기에는다소무리가있어서이에대한추가적인연구가필요할것으로생각한다. 방광확대술에의한합병증은크게내과적합병증과외과적합병증으로나눌수있다. 내과적합병증으로는전해질불균형과점액의분비, 비타민결핍과요로감염등이포

5 602 대한비뇨기과학회지 : 제 49 권제 7 호 2008 함되며외과적인합병증으로는장폐색과방광천공, 문합부위요누출등이있다. 대개의경우내과적합병증은보존적치료로대부분회복되는경우가많아서수술과관련된치명적인합병증은대개외과적인합병증과관련된다. 9,19-21 본연구에서가장빈번하게보고된합병증은마비성장폐색증으로대상환자의 25% 에서수술직후, 혹은추적관찰기간중에마비성장폐색을경험하였다. 이는대상환자중많은부분을차지하고있는척수손상환자의경우신경탓방광뿐아니라신경탓장 (neurogenic bowel) 에따른장운동저하가동반되어있기때문으로생각한다. 실제로많은신경학적병변을동반한환자들의경우에수술후장운동의회복에징후가신경학적인병변이없는다른환자들과비교해볼때늦게나타나는것을관찰할수있는데, 이와같이척수손상환자를비롯한신경탓장에따른합병증발현의위험성이높은환자들은수술후에적절한대변완화제사용과좀더엄격한식이조절등과같은추가적인조절이필요하다. 이외에도 12명의환자가점액성분비물로인한폐색을경험한것으로나타났는데, 비록회장을이용한방광확대술이구불창자를이용한경우보다점액성분비물이상대적으로적다고는하지만소장에서분비되는점액의제거가원활히이루어지지않을경우방광결석을형성하거나폐색에이은방광천공을야기할수있으므로주의를요한다. 점액의분비양상은환자개인에따라서차이를보이는데, 점액의양이많거나반복적인폐색을야기하는경우에는주기적인자가세척과보다굵은도뇨관을통한청결자가도뇨법을통해점액성분비물을적절히배출할수있도록교육하는것이중요하다. 최근에는방광확대술에사용되는대체재료에대한연구가진행되고있다. 아직은동물실험에머무르고있으나자연물질로는경막, 복막, 태반과같은물질에서부터테플론, 실리콘등의합성물질에이르기까지방광을대체할만한이상적인물질을찾고자하는노력을통해위장관을이용할때발생가능한합병증의발현을줄이고자하는연구자들의노력이계속진행되고있다. 22 국내에서도 Byun 등 23 은자가근육줄기세포가유착된합성물질을이용한방광확대술의동물실험결과를통해서이런방광대체물질의가능성에대해보고한바있다. 저자들이아는한본연구는국내에서가장많은환자를대상으로한장기추적관찰에대한보고이다. 저자들은본연구를통해서방광확대술의장기적인임상경험을정리하여보고함으로써국내에서의방광확대술의임상적효용성과안정성을평가하는기초자료로서활용될수있을것으로생각한다. 결 회장을이용한 Goodwin형방광확대술은신경탓방광등으로인해발생한높은방광내압, 방광순응도감소, 심한위축성방광을보이는환자에게있어낮은합병증과높은수술성공률을보이며장기적으로우수한임상성적을보이는치료법이다. 다만술전고등급혹은양측성방광요관역류가있는환자의경우방광확대술단독만으로방광요관역류의소실을기대하기힘든경우가많으므로이에대한추가적시술을고려해야할것으로판단된다. 론 REFERENCES 1. Greenwell TJ, Venn SN, Mundy AR. Augmentation cystoplasty. BJU Int 2001;88: Blaivas JG, Weiss JP, Desai P, Flisser AJ, Stember DS, Stahl PJ. Long-term followup of augmentation enterocystoplasty and continent diversion in patients with benign disease. J Urol 2005;173: Kurzrock EA, Baskin LS, Kogan BA. Gastrocystoplasty: long-term followup. J Urol 1998;160: Smith JJ 3rd, Swierzewski SJ 3rd. Augmentation cystoplasty. Urol Clin North Am 1997;24: Chong CI, Yoon KH, Sung GT, Kwon HY, Yoon JH. An experience of augmentation gastrocystoplasty in the treatment of a child with spastic neurogenic bladder. Korean J Urol 1995;36: Yang KM, Jeon HJ, Han SW. The clinical experience of the ureterocystoplasty in neurogenic bladder. Korean J Urol 2005; 46: Landau EH, Jayanthi VR, Khoury AE, Churchill BM, Gilmour RF, Steckler RE, et al. Bladder augmentation: ureterocystoplasty versus ileocystoplasty. J Urol 1994;152: Leng WW, Blalock HJ, Fredriksson WH, English SF, McGuire EJ. Enterocystoplasty or detrusor myectomy? Comparison of indications and outcomes for bladder augmentation. J Urol 1999;161: Goodwin WE, Winter CC, Barker WF. "Cup-patch" technique of ileocystoplasty for bladder enlargement or partial substitution. J Urol 2002;168: Kim YB, Park WH, Shim HB. The long-term outcomes of augmentation cystoplasty in spinal cord injury patients. Korean J Urol 2003;44: Lee JS, Mah SY. The clinical experience of the bladder augmentation with Goodwin's ileal cup-patched bladder. Korean J Urol 2003;44: Cho MK, Song HC, Seo KS, Kim JS, Rim JS. An experience of spastic neurogenic bladder treated with augmentation cystoplasty and external urethral sphincterotomy. Korean J Urol

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Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical