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1 Korean J Urol Oncol 2015;13(1):11-16 정위성방광대치술을시행받은방광암환자의기능적결과및삶의질 1 국민건강보험공단일산병원비뇨기과, 2 연세대학교의과대학강남세브란스병원비뇨기과학교실 박상언 1 ㆍ조강수 2 Functional Outcomes and Quality of Life after Orthotopic Bladder Substitution in Bladder Cancer Patients Sang Un Park 1, Kang Su Cho 2 1 Department of Urology, National Health Insurance Service Ilsan Hospital, Goyang, 2 Department of Urology, Gangnam Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea Radical cystectomy is the golden standard treatment for muscle-invasive bladder cancer. Urinary diversion is the prerequisite procedure after cystectomy and various type of urinary diversion has been introduced. Urinary diversion carries surgical morbidities, postoperative complications in terms of urinary function and sexual function, and issues for quality of life, which are important considerations for selecting urinary diversion. Ileal conduit urinary diversion and orthotopic bladder substitution have been regarded as the representative urinary diversion after radical cystectomy. There have been great efforts to compare the functional outcomes and quality of life between these two types of urinary diversion. Although orthotopic bladder substitution seems to a more natural and desirable urinary diversion, the currently available evidence is insufficient to draw a conclusion that orthotopic bladder is an absolutely superior form of urinary diversion. However, the vast majority of studies demonstrated that orthotopic neobladder urinary diversion shows at least equal or a marginally better quality of life scores compared to ileal conduit diversion. The favorable outcomes of orthotopic neobladder would be more pronounced especially when considering relatively young and healthy patients. (Korean J Urol Oncol 2015;13:11-16) Key Words: Urinary bladder neoplasms, Urinary diversion, Quality of life 서 근치적방광절제술은근침윤성방광암환자에서표준적인치료법으로받아들여지고있다. 근치적방광절제술후 Received March 23, 2015, Revised April 1, 2015, Accepted April 10, 2015 Corresponding Author: Kang Su Cho, Department of Urology, Gangnam Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul , Korea. Tel: , Fax: , kscho99@yuhs.ac 론 에는필연적으로요로전환술이시행되어야하는데그방법으로회장도관요로전환술, 비실금형요로전환술및정위성방광대치술등의방법이이용되고있다. 다양한요로전환술의방법중에서술식의선택에따라환자의일상적인생활방식에영향을줄수있을뿐만아니라, 궁극적으로삶의질에영향을미치게되므로환자및보호자와충분한상담을통해신중히결정해야한다. 요로전환술중정위성방광대치술은 1980년대이후종양학적으로안정성이입증되었고, 술기의발달로사망율과이환율이감소하여널리시행되고있다. 1,2 정위성방광대치술은외부집뇨기와같은신체변화가없으며, 카테터등의이용없이자가배뇨가가능하여정상적인생활이가능하다는장점을가진다. 반면회장 11

2 12 대한비뇨기종양학술지 : 제 13 권제 1 호 2015 도관요로전환술에비해긴수술시간, 수술후요실금및자가배뇨불능에대한위험성이있어선택을주저하기도한다. 정위성방광대치술이회장도관요로전환술에비하여자연스러우며바람직한형태이기는하나적절한배뇨기능이보장되지않는다면회장도관요로전환술에비하여삶의질측면에서오히려불량한결과를초래할수도있는것이다. 이에저자들은정위성방광대치술을시행받은방광암환자의수술후기능적결과및삶의질에초점을맞추어알아보고자한다. 본론 1. 기능적결과 : 배뇨기능정위성방광대치술의궁극적인목표는외부집뇨기, 카테터등의보조기구가없이요실금및요폐가없는정상적인자가배뇨를가능하게하는것이다. 이를위해서는외요도괄약근이보존되어야하고요저장기에낮은내압으로적절한용적을유지하는것이필수적이다. 따라서신방광은구의형태가되어야하며, 비관성화 (detubularization) 를통해보통 ml의방광용적을확보할수있게된다. 지난 20여년간정위성방광대치술후배뇨기능을평가한많은연구들이보고되어왔다 (Table 1) 수술직후에는대부분의환자에서요실금이발생하는데이는방광의기능적용적이작고요도괄약근의기능이회복되지않음에서기인한다. 수술 1년후주간요자제는 88-95% 로보고되고있다. 14,17,18 반면야간요자제는 66-93% 로주간요자제에비해낮게보고되고있다. 7,19-21 국내보고에따르면수술 1년후주간과야간모두에서요자제가가능한환자는 85% 였다. 9 Studer 등 15 은 20년간총 482명의정위성방광대치술의경험을보고하였는데, 수술후 1년시점에서주간및야간요자제능을확보한것이각각 92% 및 79% 였으며, 최종추적시점에서 93% 의환자가지속적인자가배뇨가가능하였다고보고하였다. 수술후 1년동안요자제능이회복되며, 이후안정기로접어드는양상을보였다. 한번이라도잔뇨가 100ml 이상이었던환자는 22% 였는데, 이는요도문합부협착이나방광출구의꼬임 (kinking) 으로인한것이었다. 이로인해 2.9% 의환자에서는배뇨를위해카테터가필요하였다. Hautmann 등 20 은독일과스위스의두기관에서시행한 1,300례이상의정위성방광대치술경험을소개하였는데, 1 년시점에서주간및야간요자제능을확보한것이각각 92% 및 80% 였다. 한편남자환자에서는 11-12% 의일시적혹은지속적인요폐가관찰되었으며, 여자환자의경우비교적수술후초기에는양호하나시간이지남에따라점점증가하여수술후 5년시점에는요폐가발생하는비율이 50% 에달한다고보고하였다. Abol-Enein 등 3 은 450명의환자중추적이가능한 344명의기능적결과를보고하였으며, 대상의평균추적관찰기간은 38개월이었다. 이중 93.3% 에서주간요자제가가능했고, 80% 에서약물치료없이야간요자제능을회복하였으며, 이들은주간에는 3-5회, 야간에는 0-2회의빈도로배뇨를한다고보고하였다. Stenzl 등 14 은 101명의여성을대상으로다기관연구를시행하였는데, 정 Table 1. Functional Outcomes of Orthotopic Neobladder Author Year No. of patients (male/female) Median Age (years) Median Follow-up (months) Daytime Continence (%) Night-time Continence (%) Self Catheterization (%) Studies mainly or only including male patients Hautmann et al (363/0) Abol-Eneinet al (353/97) Stein et al (169/40) 69 (mean) Studer et al (424/40) (after 1 year) 79 (after 1 year) 7 Nam et al (20/0) Novara et al (105/8) Ahmadi et al (179/0) 70 (mean) 54 (mean) Studies only including female patients Stenzl et al Granberg et al Ali-el-Dein et al (mean) 54 (mean) Stein et al Jentzmiket al Anderson et al (mean) 37 (mean) Pichler et al

3 박상언ㆍ조강수 : 방광암환자에서정위성방광대치술 13 상배뇨가가능한환자는 62명 (82%) 이었고배뇨간격은평균 3시간간격, 잔뇨는 150ml 이하로측정되었다. 방광잔뇨로인해 1회이상카테터도뇨가필요한환자는 11% 였으며, 그중 1명만이지속적인카테터도뇨가필요했다. 술기의발달로근치적방광절제술과정에서신경보존술을같이시행할수있게되었는데이러한신경보존술은남녀모두에게서방광대치술후요자제능을향상시키는데도움이될수있다. El-Bahnasawy 등 22 은신경보존술을시행하지않았을때와비교하여신경보존술을시행하였을때기능적요도길이 (functional urethral length) 가길어지고최대요도압력이증가했다고보고하여신경보존술의당위성에대해주장하였다. 정위성방광대치술의종류에따른배뇨양상은큰차이가없다고알려져있다. 신방광의기능적목적인요저장능과방광내압력을낮게유지하는기능은결장을쓰는 Mainz 방법에비해회장을이용한 Studer법이나 Hautmann의방법을사용하였을때더좋다는보고들이있다. 23 이는결장을사용하였을때비관성화를시행하였음에도불구하고근육 수축이더많이일어나는것이원인으로생각된다. 결장을사용한신방광의경우식사후에생리적반사로방광내압력이증가한다는보고가있고, 24 요역동학검사에서회장을이용한신방광보다방광내압력이높다는보고들이있다. 하지만그차이가배뇨양상에영향을미치지는않았으며술식에따른배뇨양상의의미있는차이는없었다. 2. 기능적결과 : 성기능근치적방광절제술후배뇨증상과더불어성기능의회복도중요한요소이다. 성기능은신경혈관다발의보존유무, 종양학적병기, 나이와밀접한상관관계가있는것으로알려져있다. Schoenberg 등은신경보존술을시행한 101명의남성방광절제술환자에서성기능과나이에관한 10년간의추적관찰결과를발표하였는데 49세이하환자의 62%, 50세에서 59 세환자의 47%, 60세에서 69세환자의 43%, 70세이상환자의 20% 에서성기능이보존되었다. 25 Studer 등은 32개월의추적관찰기간동안 22.4% 가정상적으로발기력이유지되 Table 2. Comparison of Quality of Life Between Ileal Conduit and Orthotopic Neobladder Author Bjerre et al. 28 Mansson et al. 37 Kitamura et al. 35 Fujisawa et al. 31 Hobisch et al. 34 McGuire et al. 38 Dutta el al. 29 Hara et al. 33 Kulaksizoglu et al. 36 Gilbert et al. 32 Erber et al. 30 Year No. of patients NB (38) IC (29) NB (38) CR (16) IC (38) NB (21) CR (22) IC (36) NB (36) IC (23) NB (69) IC (33) NB (38) CR (16) IC (38) NB (49) IC (23) NB (48) IC (37) NB (17) IC (51) NB (122) IC (66) NB (115) IC (146) Time of QOL assessment from surgery NB 1 year IC 4.8 years NB 48 months CR 24 months IC 42 months Not reported NB 31.3 months IC 44.8 months NB 28.3 months IC 55.5 months NB 48 months CR 24 months IC 42 months 2.7 years NB 46 months IC 131 months 27.7 months 2.9 years Not reported Major findings Incontinence more bothersome in IC, other parameters equivalent No difference overall groups Pts with IC more likely to have trouble with public restroom No differences found NB better in all domains, more like to recommend to friend Patients with IC have significantly decreased mental health QOL NB better on several domains, but only marginal difference after adjusting for age, stage, sex No difference in both group No difference in both groups More urinary leak in NB NB: neobladder, IC: ileal conduit, CR: continent reservoir, QOL: quality of life. In favour of ileal neo-bladder

4 14 대한비뇨기종양학술지 : 제 13 권제 1 호 2015 었고 15.4% 에서는약의도움을받아발기가가능했다고보고하였고, 20 Kessler 등은 331명의환자를대상으로한연구에서는 65세를기준으로하였을때 65세이하의환자에서신경보존술을시행한경우발기력의유의한회복을보였다고보고하였다. 26 일본에서진행된 45명의환자를대상으로한연구에서발기력은수술 3년후에 49%, 5년후에 79% 에서회복되었고성관계는 5년후에 57% 에서가능하였으며가장중요한인자는나이였다 삶의질요로전환술을선택함에있어종양학적결과는큰차이가없음이밝혀져있다. 따라서요로전환술의종류를선택함에있어삶의질은중요한판단기준이될수있다. 일반적으로정위성방광대치술이외부집뇨기가필요한회장도관요로전환술과비교하여삶의질이높을것으로여겨진다. 근치적방광절제술을시행받은환자들의삶의질을결정하는요인들로는요자제능, 성기능, 신체이미지, 위장관장애등이중요한판단기준이되며, 각항목에대해평가한다수의문헌들이있으며, 대부분의연구에서다른요로전환술과비교하여정위성방광대치술이삶의질에서비슷하거나우수한결과를보여주었다 (Table 2) 년발표된 Gerharz의기존문헌고찰에의하면정위성방광대치술이다른요로전환술과비교하여삶의질이우월함을증명할수없다고하였다. 39 배뇨장애나성기능장애는어떠한요로전환술을선택하여도생길수있는문제이지만기존문헌들에서근치적방광절제술후삶의질지표가정상인과비교하였을때큰차이가없는연구들이상당부분을차지하고있었다. 이러한이유로몇가지를제시하고있는데첫째, 삶의질측정을위한도구들이객관성이결여되어있고둘째, 근치적방광절제술을받은환자들은수술전여러가지요로전환술에대한장단점과수술후발생가능한합병증에대해충분한설명을듣고환자의상태에맞는방법을선택하였을것이고이는수술후합병증에대한쉽게받아들이게되고높은만족도로이어진다는점이다. 셋째, 근치적방광절제술같은큰수술을받은환자들은정상적인사람들과삶의질을생각하는관점이다를수있다는점이다. 큰장애가있는사람들이나임종을앞두고있는사람들에서나타나는 well being paradox 이론이적용가능하다는것이다. 이러한이유로요로전환술기의방법보다개개인에맞는환자선택, 수술후관리가환자의삶의질을결정하는요소라고주장하였다. Metcalfe 등 40 은나이에따른차이는있지만결과적으로요로전환술의종류와삶의질은연관성이없다고보고하였다. Gilbert 등 32 은정위성방광대치술을받은환자들의삶의질이현저히낮다 고하였고가장큰원인은요실금에대한스트레스였다고보고하였다. 반면 Singh 등 41 은회장도관요로전환술을받은환자와정위성방광대치술을받은환자를비교하였을때정위성방광대치술을시행받은환자가회장도관요로전환술에비해수술후 18개월이지난후기능적, 사회적역할을잘수행할수있었고의미있게삶의질이높다고보고하였다. Hobisch 등 34 은 102명의남녀환자를대상으로한연구에서회장도관요로전환술에비해정위성방광대치술에서삶의질이월등하게좋음을보고하였다. Ali 등 42 은근치적방광절제술후정위성방광대치술과회장도관요로전환술을공인된설문지를이용하여삶의질을비교한 21편의연구 (2285명) 에대하여체계적문헌고찰을시행하였다. 이중 16편의연구에서는삶의질측면에서차이가없다고하였고, 4편의연구에서는정위성방광대치술이삶의질이우월하다고보고하였다. 다른 1편의연구에서는신체이미지점수에서는두방법의차이가없었으며, 비록배뇨로인한불편감측면에서는차이가없으나기능적측면에서는정위성방광대치술이오히려불량하다고보고하였다. 43 Dutta 등 29 과 Philip 등 44 은상대적으로젊은환자에서정위성방광대치술이삶의만족도가높은것으로보고하였다. 여러문헌들을고찰하였을때요로전환술에따른삶의질차이에대한명확한결과는도출할수없었고정위성방광대치술이다른요로전환술과비교하여삶의질이좋거나최소한나쁘지않다는경향성만확인할수있었다. 그이유로근치적방광절제술후삶의질평가를위한표준화된설문지나평가도구가없고각연구자들은다양한삶의질에관련된설문지나특별히제작된설문지를만들어서사용하여객관적인비교가어려우며요로전환술의방법을선택하는기준이각각의연구들에서다르기때문이라고생각된다. 근치적방광절제술후요로전환술의방법을선택하는기준이명확해지고삶의질을측정할수있는표준화된평가도구가개발된다면객관적이고정확한결과가도출될것으로생각되며요로전환술의방법을선택함에있어도움이될것이다. 결론정위성방광대치술은기존의요로전환술과비교하여종양학적으로안전함이입증되었고수술후일정시간이지나면배뇨기능이나성기능에서도만족할만한성과를얻고있다. 정위성방광대치술은신체이미지에대한왜곡이없고정상적인사회생활을할수있도록해주는장점이있다. 회장도관요로전환술과비교하여삶의질측면에서비슷하

5 박상언ㆍ조강수 : 방광암환자에서정위성방광대치술 15 거나우월한결과를보여주었다. 현시점에서다양한요로전환술중정위성방광대치술이기능적, 삶의질측면에서가장우월하다고단정지을수는없다. 요로전환술을선택함에있어환자의전신상태와나이, 사회적활동정도등을고려하여충분한술전상담을진행하여야한다. 정위성방광대치술은근치적방광절제술후표준적인요로전환술중하나로인정받고있으며, 특히비교적젊고전신상태가양호한환자에서기능적측면과삶의질측면에서만족할만한결과를기대할수있을것이다. REFERENCES 1. Stein JP, Lieskovsky G, Cote R, Groshen S, Feng AC, Boyd S, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol 2001;19: Gschwend JE, Fair WR, Vieweg J. Radical cystectomy for invasive bladder cancer: contemporary results and remaining controversies. Eur Urol 2000;38: Abol-Enein H, Ghoneim MA. Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation: experience with 450 patients. J Urol 2001;165: Ahmadi H, Skinner EC, Simma-Chiang V, Miranda G, Cai J, Penson DF, et al. Urinary functional outcome following radical cystoprostatectomy and ileal neobladder reconstruction in male patients. J Urol 2013;189: Ali-el-Dein B, Shaaban AA, Abu-Eideh RH, el-azab M, Ashamallah A, Ghoneim MA. Surgical complications following radical cystectomy and orthotopic neobladders in women. J Urol 2008;180:206-10; discussion Anderson CB, Cookson MS, Chang SS, Clark PE, Smith JA, Jr., Kaufman MR. Voiding function in women with orthotopic neobladder urinary diversion. J Urol 2012;188: Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R, Paiss T. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol 1999;161:422-7; discussion Jentzmik F, Schrader AJ, de Petriconi R, Hefty R, Mueller J, Doetterl J, et al. The ileal neobladder in female patients with bladder cancer: long-term clinical, functional, and oncological outcome. World J Urol 2012;30: Nam J, Cho S, Lee Y. Voiding pattern and incontinence after orthotopic ileal neobladder in male patients. Korean J Urol 2007;48: Novara G, Ficarra V, Minja A, De Marco V, Artibani W. Functional results following vescica ileale Padovana (VIP) neobladder: midterm follow-up analysis with validated questionnaires. Eur Urol 2010;57: Pichler R, Zangerl F, Leonhartsberger N, Stohr B, Horninger W, Steiner H. Orthotopic bladder replacement in women: focus on functional results of a retrospective, single-centre study. Scand J Urol 2013;47: Stein JP, Dunn MD, Quek ML, Miranda G, Skinner DG. The orthotopic T pouch ileal neobladder: experience with 209 patients. J Urol 2004;172: Stein JP, Penson DF, Lee C, Cai J, Miranda G, Skinner DG. Long-term oncological outcomes in women undergoing radical cystectomy and orthotopic diversion for bladder cancer. J Urol 2009;181:2052-8; discussion Stenzl A, Jarolim L, Coloby P, Golia S, Bartsch G, Babjuk M, et al. Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors. Cancer 2001;92: Studer UE, Burkhard FC, Schumacher M, Kessler TM, Thoeny H, Fleischmann A, et al. Twenty years experience with an ileal orthotopic low pressure bladder substitute--lessons to be learned. J Urol 2006;176: Granberg CF, Boorjian SA, Crispen PL, Tollefson MK, Farmer SA, Frank I, et al. Functional and oncological outcomes after orthotopic neobladder reconstruction in women. BJU Int 2008;102: Gburek BM, Lieber MM, Blute ML. Comparison of studer ileal neobladder and ileal conduit urinary diversion with respect to perioperative outcome and late complications. J Urol 1998;160: Steven K, Poulsen AL. The orthotopic Kock ileal neobladder: functional results, urodynamic features, complications and survival in 166 men. J Urol 2000;164: Madersbacher S, Hochreiter W, Burkhard F, Thalmann GN, Danuser H, Markwalder R, et al. Radical cystectomy for bladder cancer today--a homogeneous series without neoadjuvant therapy. J Clin Oncol 2003;21: Hautmann RE, Volkmer BG, Schumacher MC, Gschwend JE, Studer UE. Long-term results of standard procedures in urology: the ileal neobladder. World J Urol 2006;24: Ghoneim MA, Shaaban AA, Mahran MR, Kock NG. Further experience with the urethral Kock pouch. J Urol 1992;147: el-bahnasawy MS, Gomha MA, Shaaban AA. Urethral pressure profile following orthotopic neobladder: differences between nerve sparing and standard radical cystectomy techniques. J Urol 2006;175: ; discussion Iwakiri J, Gill H, Anderson R, Freiha F. Functional and urodynamic characteristics of an ileal neobladder. J Urol 1993; 149: Lobel B, Guille F, Olivo JF, Gosselin A, Goldwasser B. Variations of intestinal motor activity in bladder replacements and in the intestine. Arch Ital Urol Androl 1993;65: Schoenberg MP, Walsh PC, Breazeale DR, Marshall FF, Mostwin JL, Brendler CB. Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder

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( )Kju129.hwp 종설 요로전환술 : 회장도관에서정위성인공방광대치술까지 Urinary Diversion: Ileal Conduit to Orthotopic Neobladder Substitution 대한비뇨기과학회지제 48 권제 6 호 2007 Moon Kee Chung, Ho Kyung Seo 1 From the Department of Urology, College of