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1 대한배뇨장애및요실금학회지 : 제 5 권, 제 1 호 2001 년 6 월 J. Korean Continence Society, Vol. 5, No. 1, p57~65, June, 2001 전립선비대증환자에서경요도전립선절제술전후의전립선용적지표및잔여전립선용적비와임상지표와의관계 울산대학교의과대학비뇨기과학교실 The Correlation between Residual Prostatic Volume Ratio and Parameters of Prostate Volume and Clinical Parameters before and after Transurethral Resection of Prostate in BPH Uk Lee, Myung Soo Choo, Choung Soo Kim From the Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Purpose:Prostate volume(pv) has been known to be poorly correlated with other clinical parameters used to assess benign prostate hyperplasia (BPH), including international prostate symptom score(ipss), peak flow rate(qmax) and amount of postvoid residuals(pvr). 6) The purpose of this study was to determine Key words:benign prostatic hyperplasia, Transition zone index, Transurethral resection of prostate 교신저자 : 김청수울산의대서울중앙병원비뇨기과 서울시송파구풍납동 Tel: Fax: cskim@ if the parameters of prostate volume including PV, transition volume, transitional zone index (TZI) and residual prostatic volume ratio(rpvr) correlated well with other clinical parameters before and after transurethral resection of prostate(turp). Materials and Methods:31 men with symptomatic BPH were evaluated using IPSS, Qmax before and after TURP and the parameters of prostate volume were determined by transrectal ultrasonography(trus). The clinical outcome was evaluated by the difference(δ) in IPSS, Qmean and Qmax before and 3 months 57

2 58 after TURP. Results:PV was not correlated with ΔIPSS and ΔQmax, but transition volume(r=0.394, p=0.034) and TZI(r=0.368, p=0.049) were significantly correlated with ΔQmax. There were negative correlations between the RPVR and ΔIPSS and ΔQmax(r=-0.449, , p=0.011, 0.033). Conclusions:TRUS is a useful tool for estimating prostate weight before surgery of BPH. Transition volume, TZI and RPVR could be useful parameters to predict the IPSS and Qmax after TURP based with IPSS and Qmax before TURP. The smaller the RPVR after TURP, the better the clinical outcome. 와의상관관계에대하여는논란이있다. 4-6 이전에도 TRUS를이용하여경요도전립선절제술 (TURP) 시행전, 후의전립선의크기변화에대한보고 7 가있었지만전립선크기의변화와임상결과의상관관계에대한보고는거의없으며최근들어술전전립선용적에대한술후잔여전립선용적의비율 ( 잔여전립선용적비, residual prostatic volume ratio ; RPVR) 과임상지표와의연관성이제기되고있다. 8 이에저자들은전립선용적지표 [ 전립선전체용적 (prostate volume ; PV), 전립선이행대용적 (transition zone volume ; TZV), 이행대용적지수 (transition zone index ; TZI)] 및 RPVR과 TURP 전, 후의임상지표와의상관관계에대하여알아보았다. 서론 대상및방법 전립선비대증 (benign prostate hyperplasia; BPH) 을가진환자에서수술적치료를하기전에전립선의크기를알아보는것은중요하다. 직장수지검사, 요도방광내시경검사, 역행성요도조영술등전립선의크기를알아볼수있는많은방법들이제시되어왔지만현재까지경직장전립선초음파 (TRUS) 가가장나은결과를얻고있다. 1,2 Watanabe 등 3 은 TRUS를이용하여전립선크기를측정하였고정확한결과를보고하였다. 하부요로증상을호소하는 BPH 환자에서 TRUS를통한전체전립선용적과 BPH의정도를예측하는임상지표 (IPSS, 요류속도등 ) 들과의연관성이높지않다고알려져있고전립선이행대용적지수와환자의증상정도 1998년 9월부터 1999년 9월까지하부요로증상을호소하여 BPH가의심되었던환자중 TRUS를시행하고그후에 TURP를받은 31명을대상으로하였다. 당뇨병등의내과적질환이있는환자, 신경계질환이나뇌질환의과거력이있는환자, 골반강내수술을한과거력이있는환자, 방광기능에영향을줄수있는약물을복용하고있는환자, 전신상태가불량한환자나다량의잔뇨를보이는대상부전상태의환자는제외하였고 PSA가 4ng/ml이상인경우는전립선조직검사를통하여전립선암이없음을증명하였다. 수술전에국제전립선증상점수 (international prostate symptoms score; IPSS), 최대요

3 전립선비대증환자에서경요도전립선절제술전후의전립선용적지표및잔여전립선용적비와임상지표와의관계 59 속과평균요속을검사하였으며 TURP 3개월후전립선증상점수 (IPSS) 와요속검사를다시시행하여술전자료와의차이를구하여변화량 (Δ) 을계산하였고수술전에확인된전립선용적지표가술전의증상과상관관계가있는지, 술후의증상의호전및최대요속의개선정도를예측할수있는인자로서역할을할수있는지를알기위해알려진전립선용적지표및 RPVR와술전, 후의임상지표와의상관관계를알아보았다. PV와 TZV은타원체에대한부피공식 [ 부피 =0.52 최대전후직경 (mm) 최대좌우직경 (mm) 최대두미직경 (mm)] 을이용하여계산하였고 TZI는 TZV을 PV으로나눈값으로계산하였다. 그리고, TURP 로절제된조직의무게를전립선의비중인 1.010으로나누어계산된절제된조직의용적을 PV에서빼서잔여전립선용적 (residual prostatic volume; RPV) 을구하였고, 이 RPV값을 PV으로나누어 RPVR을계산하였다. TRUS에사용된초음파기계는 real-time scanning with Convex 9.5MHz broadband transducer(atl, HDI-3000) 이었다. 술전, 후의임상지표의변화는 paired T test 로유의성을알아보았고, 임상지표와전립선용적지표및 RPVR 간의상관관계분석은 Pearson correlation을이용하여계산하였다. 결과 31명대상환자의평균연령은 67.4세 (52-90세 ) 였으며평균추적관찰기간은 122일 (90-150일 ) 이었다. 평균 PSA는 6.14±7.50ng/ml 였으며 PV, TZV, TZI, 경요도전립선절제용적, RPVR 의평균은각각 53.02±21.73cc, 27.20±14.29cc, 0.50±0.14, 22.23±15.74cc, 0.61±0.18이었다 (Table 1). 평균 IPSS는수술전 24.35±5.77에서수술후 13.76±8.30으로 ΔIPSS는 10.59±7.89이었고 (p<0.001) 평균 Qmax는수술전 10.26± 4.00ml/sec 에서수술후 19.92±6.73ml/sec으로 ΔQmax는 9.66±5.83ml/sec이었다 (p<0.001). 평균 Qmean도수술전 4.94±2.53ml/sec에서수술후 10.25±4.22ml/sec로 ΔQmean은 5.31 ±4.24ml/sec이었다 (p<0.001)(table 2). PV는수술전, 후 IPSS, Qmax, Qmean 및 ΔIPSS, ΔQmax, ΔQmean과는상관관계가 Table 1. Range and mean level of prostate volume indices in BPH patients Parameter Mean±SD Range Age(yrs.) 67.35± Serum PSA(ng/ml) 6.14± Prostate volume(cc) 53.02± Transition zone volume(cc) 27.20± Transition zone index 0.50± Resected tissue volume(cc) 22.23± RPVR 0.61±

4 60 없었다. TZV은다른인자와는상관관계가없었고 ΔQmax와양의상관관계가있었다 (r=0.394, p=0.034). TZI도다른인자와는상관관계가없었고 ΔQmax와만양의상관관계가있었다 (r=0.368, p=0.049). RPVR 은수술전 IPSS나수술전 Qmax와는상관관계가없었으나 ΔIPSS와 ΔQmax와는음의상관관계가있었다 ( 각각 r=-0.449, ; p=0.011, 0.033)(Table 3)(Fig. 1). 고찰 1970 년 McNeal 9 에의해전립선의해부조 직학적성상이밝혀지면서 BPH에대한요로폐색은주로전립선이행대조직의양성증식에의한결과임을알게되었고 TRUS의발달에힘입어전체전립선의용적과함께전립선이행대의용적측정이가능하게되었다. 그리고, 임상적으로 BPH의객관적이고정확한진단을위해현재까지노인남성에있어서배뇨증상의정도, 요속검사결과와전립선용적지표사이의상호간관계를규명하고자하는많은연구들이시행되고있다. BPH 환자들이대부분고령이고수술의위험성이항상존재하므로 TURP 등의수술적치료를하기전에전립선크기를미리파악하는것은수술의시간을예측하여그만큼 Table 2. Descriptive statistics of the various clinical parameters(mean±sd) Before TURP After TURP Differences between values before and after TURP(p-value)* IPSS 24.35± ± ±7.89(<0.001) Qmax(ml/sec) 10.26± ± ±5.83(<0.001) Qmean(ml/sec) 4.94± ± ±4.24(<0.001) SD, standard deviation ; *paired t test Table 3. Correlations(and p value) between BPH indices and various clinical parameters PV TZV TZI TUR volume RPVR IPSS Preop r=0.074(0.651) r=0.030(0.860) r=ꠏ0.093(0.586) r=0.213(0.187) r=ꠏ0.152(0.349) Postop r=0.077(0.672) r=ꠏ0.179(0.327) r=ꠏ0.369(0.057) r=ꠏ0.069(0.703) r=0.248(0.164) ΔIPSS r=0.092(0.622) r=0.292(0.117) r=0.339(0.067) r=0.341(0.060) r=ꠏ0.449*(0.011) Qmax Preop r=ꠏ0.226(0.071) r=ꠏ0.266(0.117) r=ꠏ0.037(0.830) r=ꠏ0.270(0.096) r=0.125(0.448) Postop r=0.016(0.926) r=0.044(0.803) r=0.054(0.760) r=0.054(0.749) r=ꠏ0.087(0.609) ΔQmax r=0.278(0.130) r=0.394*(0.034) r=0.368*(0.049) r=0.370*(0.040) r=ꠏ0.385*(0.033) Qmean Preop r=ꠏ0.275(0.112) r=ꠏ0.257(0.105) r=ꠏ0.105(0.515) r=ꠏ0.213(0.166) r=0.077(0.620) Postop r=0.037(0.839) r=0.016(0.932) r=ꠏ0.026(0.889) r=ꠏ0.079(0.662) r=0.147(0.414) ΔQmean r=0.263(0.160) r=0.134(0.497) r=0.012(0.953) r=0.010(0.957) r=0.129(0.497) Pearson correlation coefficient(r) was used. * ; Correlation is significant at the 0.05 level(2-tailed).

5 전립선비대증환자에서경요도전립선절제술전후의전립선용적지표및잔여전립선용적비와임상지표와의관계 61 r=0.394 p=0.034 r=368 p=0.049 Δ Δ a a b b 1 r= p= r= p= Δ Qmax (ml/sec) Δ IPSS c d d Fig. 1. The correlations between: a, b and c, ΔQmax and transition zone volume, transition zone index and residual prostatic volume ratio(rpvr); d, IPSS and RPVR

6 62 위험도를줄일수있어서중요하다. 하지만불행히도직장수지검사, 역행성요도조영술, 방광요도경검사, 요도내압측정등의검사들로는전립선의크기를정확하게알아내기가힘들며전립선크기가크면클수록그오차는더커진다. 1,2,10 전립선의크기를좀더정확하게측정하기위하여사용되고있는 TRUS에대하여 1970 년대부터논의가있었다. 3,11,12 Tewari 등 13 은 TRUS는경제적이며사용이쉽고비관헐적으로 MRI에비교될정도의정확도를가지고있다고주장하였고 Harada 등 14 은 BPH 환자에서 TRUS를이용하여정상전립선조직과전립선종의구분이가능하다고하였으며 Jones 등 15 은경복부전립선초음파를시행하여정상전립선조직과전립선종을구분하였다. 따라현재는전체전립선조직에서전립선종을구분하여전립선종만의크기를측정할수있게되었다. 초음파를이용하여전립선의용적을측정하는많은방법들이제시되어왔다. Terris와 Stamey는편장-타원형공식 (prolate-spheroid formula) 을이용하여실제전립선의용적에가장근접한값을구할수있으며전립선크기가 80ml 미만이면더욱근접한다고보고하였다. 이론적으로는수술전에시행된 TRUS로측정된전립선의총용적은수술후에 TRUS 를시행하여얻은전립선의총용적과실제로 TURP로얻은조직의용적의합과동일해야하지만 TURP 동안에조직의분실, 불완전한절제로남은잔여조직등으로차이가있게된다 Kaplan 등 2 은요로폐색증세를보이는 BPH 환자 61례에대한전향적연구에서 TZI와임상증상이나 Qmax와의미있는상관관계를보고하였고심과이 20 는 BPH이의심되는환자 86명에대한연구에서 TZV과 TZI가 IPSS나 Qmax와유의한상관관계가있다고하였다. 하지만 Lepor 등 21 은 BPH 환자 93명에대한조사에서 TZI와증상점수사이에직접적연관은없는것으로보고하였고단지최대요속과미약한연관이있다고하였으며이등 22 은 BPH이의심되는 149명의환자를대상으로 TZI와임상증상및최대요속에대한연구에서상관관계가없다고하였다. Greene 등 23 은 BPH를가진환자들과임상증상이없는대조군연구에서 TZV이각각 24.8±14.4ml 와 6.14±8.2ml 로 BPH군이대조군보다큰 TZV을가진다고보고하였으며 Tewari 등 24 은 BPH에대한 finasteride의효과에대한연구에서 finasteride에반응하는군들이더큰 TZV의감소를가져왔으며 TZV, TZI 그리고요속의개선정도와는연관관계가있다고하였다. 아직 TZI와 BPH 환자의증상및 Qmax 사이의연관관계에대하여는논란이있고본연구에서는관련성이없는결과를얻었다. 이는 Jensen 25 이제시한요류측정술의측정방법상의문제점, BPH의자연경과및병태생리에대한완전한이해의부족, 하부요로증상과생리학적인방광출구폐색사이의차이점등을원인으로생각해볼수있겠고그외에 Abrams 26 가하부요로증상의발생기전으로제시한전립선에의한요도폐색, 방광의수축력저하, 불안정성방광등의요인들이병원에내원한환자들에서서로혼재하기때문에전립선에의한요도폐색을진

7 전립선비대증환자에서경요도전립선절제술전후의전립선용적지표및잔여전립선용적비와임상지표와의관계 63 단하는데유용한 TRUS의전립선용적지표들이임상지표들과연관관계가일관성이없게보고되는것으로생각된다. Otani 등 27 은 TURP의치료결과를알아보기위하여 %IPSS( 수술전 / 수술후 ), ΔIPSS( 수술전 / 수술후 ) 와 ΔQmax( 수술후 / 수술전 ) 을이용하였고 TZI는 %IPSS, ΔIPSS와 ΔQmax의세인자모두와상관관계가있다고보고하였다. 또, Chen 등 8 은 BPH환자에서 TURP를시행하고그치료결과를파악하는방법으로술후 16주후에다시 TRUS를시행하여 TURP이후에남은전립선용적을측정하였고이용적을무게로환산한값과술전 TRUS 로알아낸 PV에서 TURP로절제된전립선용적을빼서계산된전립선잔여무게는거의일치되는결과를얻었다. 또계산된잔여전립선무게와수술전후의 American Urological Association(AUA) symptome score, Qmax, Qave의세변화량과는음의상관관계가있다고보고하였고이것은전립선의크기나환자의연령과는상관이없었다. 저자들도역시 TURP의효과를알아보기위하여 Δ IPSS( 수술전 / 수술후 ) 와 ΔQmax( 수술후 / 수술전 ) 를이용하였으며 TZV, TZI, RPVR은각각 ΔQmax와통계학적으로상관관계가있었다. 더욱이 RPVR은 ΔIPSS와도상관관계가있는결과를얻었다. 저자들은전립선용적지수들은수술전에임상지표와의상관관계는미약한결과를얻었지만 TZV, TZI, RPVR 등과 ΔQmax와 ΔIPSS와의관계로미루어보아수술전에측정된전립선용적지표중 TZV과 TZI는수술전에 TURP를결정하고그술후결과를예측하는데도움이될것이며수술이후에 계산된 RPVR로서증상개선정도를예측하는데도움을얻을수있을것이다. 즉 TURP 후에적은 RPVR을가지게되면더나은임상결과를얻을수있다는것을알수있다. 결론 비록 TZV과 TZI의수술전임상지표와의관계는지금논란의대상이되고있어그이용에주의가필요하지만 TURP이전에시행된 TRUS는전립선의크기에대한충분한자료를제공하고 TURP를선택하는데참고자료가될수있다. TZV과 TZI가클수록수술전에대한수술후의 Qmax의변화량이커서더나은 Qmax를얻게되며 TURP로제거된전립선의용적을이용하여 RPVR을계산하면그수치로 Qmax뿐아니라 IPSS의변화까지예측할수있을것으로보인다. TRUS는비관헐적이며 TZV을측정하고 TZI를계산함으로서 BPH을진단할수있고 TURP에의해제거된용적을이용하여 RPVR을측정한다면 TURP에의한수술결과를예측할수있는유용한방법이될것으로생각된다. References 1. Miller SS, Garvie WH, Christie AD. The evaluation of prostate size by ultrasonic scanning: a preliminary report. Br J Urol 1973; 45: Kaplan SA, Te AE, Pressler LB, Olsson

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슬라이드 1

슬라이드 1 Proposed Korean guideline for the diagnosis of BPH Hyun Woo Kim The Catholic University of Korea BPH Guideline AHCPR guideline on BPH (1994) AUA guideline on BPH (2003) EAU guideline on BPH (2004) International