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1 전남의대학술지제 46 권제 3 호 Chonnam Medical Journal Vol. 46, No. 3, pp DOI: /cmj 복막외복강경하근치적전립선적출술 : 103 예의임상경험및학습곡선 전남대학교의과대학비뇨기과학교실 정호석ㆍ윤부현ㆍ기현정ㆍ나성웅ㆍ황의창ㆍ임창민ㆍ정승일ㆍ권동득 * ㆍ박광성ㆍ류수방 Extraperitoneal Laparoscopic Radical Prostatectomy: Clinical Experience and Learning Curve with 103 Cases Ho Suck Chung, Bu Hyeon Yun, Hyun Chong Ki, Seong Woong Na, Eu Chang Hwang, Chang Min Im, Seung Il Jung, Dong Deuk Kwon*, Kwangsung Park and Soo Bang Ryu Department of Urology, Chonnam National University Medical School, Gwangju, Korea To estimate the early operative results and learning curve of extraperitoneal laparoscopic radical prostatectomy in 103 patients. Between March 2006 and January 2009, 103 patients with clinically organ-confined prostate cancer who underwent laparoscopic radical prostatectomy were enrolled in this study. Surgical morbidity and the oncologic and functional results of the groups were compared to evaluate the learning curve. The patients' mean age was 63.3±8.1 years, and their mean serum PSA was 14.1±7.6 ng/ml. The mean operating time and hospital stay were 265±83 minutes and 10.6±3.6 days, respectively. The mean postoperative period of an indwelling Foley catheter was 13.8±2.7 days. The positive surgical margin rate was 26.2%. After a mean follow-up of 15.5±9.4 months, a PSA relapse was observed in 3 (8.6%) patients in the first period. Continence and sufficient erection rates were about 80% and 45% after 6 months, respectively. Analysis of the learning curve revealed differences in the operating time, estimated blood loss, and complication rate but showed no influence on hospital days, indwelling Foley catheter days, or positive surgical margin rate. Although laparoscopic radical prostatectomy requires significant expertise with a learning curve, morbidity is low and the oncologic continence results were promising. Extraperitoneal laparoscopic radical prostatectomy could be considered as the first safe treatment for patients with organ-confined prostate cancer. The learning curve for extraperitoneal laparoscopic radical prostatectomy seemed to show no complete plateau in this study. It depended not only on technical skills, but also on self-perceived skills. Standardized expectations and operative outcomes could help to define the true learning curve for extraperitoneal laparoscopic radical prostatectomy. Key Words: Prostatic neoplasms, Laparoscopy, Prostatectomy 접수일 : 2010 년 7 월 22 일, 게재결정 : 2010 년 8 월 24 일 * 교신저자 : 권동득, , 전남대학교의과대학비뇨기과, Phone: , FAX: , urokwon@gmail.com 170

2 정호석외 9 인 : 복막의복강경하근치적전립선적출술 171 서론근치적전립선적출술은국소전립선암의표준치료로이용되고있으며복강경하근치적전립선적출술 (laparoscopic radical prostatectomy; LRP) 은 1992년 Schuessler 등 1 이처음보고한이래 Guillonneau 등 2,3 에의해보편화되었고국내에서는 2001년처음으로시행되었다. 4 LRP는경복막적접근방법 (transperitoneal laparoscopic radical prostatectomy; TLRP) 과복막외접근을통한방법 (extraperitoneal laparoscopic radical prostatectomy; ELRP) 을통하여시행할수있다. TLRP는복막을통한수술이므로수술공간의조기확보등의장점이있지만잠재적인복강내합병증을초래할가능성이있다. 기존에는 TLRP이전통적으로시행되어왔었으나 1997 년 Raboy 등 5 이 ELRP를처음소개한이후여러장점들이보고되면서 ELRP의시술이증가하고있으나, 6-11 아직까지국내에서는 ELRP에대한보고는미비한실정이다. 이에저자들은단일술자에의해시행된 103예의 ELRP 를대상으로수술결과와합병증그리고종양학적및기능적결과를분석하여 ELRP의효과및유용성을평가하고더나아가이수술의학습곡선을조사하고자하였다. 대상및방법 1. 대상 2006년 3월부터 2009년 1월까지전립선암으로진단후단일술자에의해복막외복강경하근치적전립선적출술을시행받은환자들중 3개월이상추적관찰이가능하였던 103명의환자들을대상으로하였다. 환자의평균연령은 63.3±8.1세였고, 평균 추적관찰기간은 15.5±9.4개월이었으며, 평균체질량지수 (body mass index, BMI) 는 23.5±2.5 kg/m 2 이었다. 평균혈중전립선특이항원 (prostate-specific antigen, PSA) 은 14.1±7.6 ng/ml 였으며, 평균전립선용적은 30.6±18.5 ml였다. 술전임상병기는 ct1, ct2, ct3가각각 36예 (35.0%), 47예 (45.6%), 20예 (19.4%) 였고, Gleason 점수가 6점이하는 43예 (41.7%), 7점은 35예 (34.0%), 8점이상은 25예 (24.3%) 였다 (Table 1). 2. 방법저자는 1) 술전환자준비 2) 복막외강의확보및 trocar 삽입 3) 전립선과방광경부노출및내골반근막의절개 ( 배부정맥총의결찰, 방광경부의박리, 정낭의노출및박리 ) 4) Denonvillier 근막의절개및전립선측면혈관경의처리 5) 전립선첨부의박리및배부정맥총의절단 6) 방광요도문합 7) 골반강과 trocar 삽입부위의출혈확인점검순으로술기를시행하였다. 골반림프절절제술은혈중 PSA가 10 ng/ml 이상이거나 Gleason 점수가 7점이상인경우에서시행하였고, 신경보존술식은주로 65세이하에서술전발기가가능한환자중 ct2 이하이고술전 PSA가 10 ng/ml 이하이며 Gleason 점수가 7점이하인환자에서시행하였다. 모든환자에서수술시간, 실혈량, 술중후합병증, 수혈여부, 입원일수, 요도카테터삽입기간등의수술관련정보와절제연양성, PSA 재발, 요자제, 발기능의종양학적및기능적결과를조사하였다. 또한단일술자에대한학습곡선을분석하기위하여 103예를수술시행횟수에따라초기군 35 예, 중기군 33예, 후기군 35예로나누어비교분석하였다. 생화학적재발은 PSA 값이두번이상연속하여 0.2 ng/ ml 이상일때로정의하였고, 요자제는패드를전혀사용하지않거나요실금은없으나불안하여패드를사용하는경우 Table 1. Characteristics of patients All groups Group 1 Group 2 Group 3 Mean age (years) 63.3± ± ± ±7.3 Mean BMI (kg/m 2 ) 23.5± ± ± ±2.4 Mean serum PSA (ng/ml) 14.1± ± ± ±7.1 Mean prostate volume (ml) 30.6± ± ± ±18.2 Clinical stage (%) T1 36 (35.0) 13 (37.1) 12 (36.4) 11 (31.4) T2 47 (45.6) 16 (45.7) 14 (42.4) 17 (48.6) T3 20 (19.4) 6 (17.1) 7 (21.2) 7 (20.2) Gleason s score (%) 6 43 (41.7) 15 (42.8) 14 (42.4) 14 (40.0) 7 35 (34.0) 12 (34.3) 11 (33.3) 12 (34.3) 8 25 (24.3) 8 (22.9) 8 (24.2) 9 (25.7) BMI, body mass index; PSA, prostate-specific antigen.

3 172 전남의대학술지제 46 권제 3 호 2010 까지로, 발기능은자연발기또는경구약제로발기되어이성과성교가가능한경우로정의하였다. 통계분석은 SPSS 12.0을사용하였으며두군간의자료비교는 Student's t-test와 chi-square test를이용하였고, p값이 0.05 미만인경우통계적으로유의성을가진것으로판단하였다. 결과 1. 수술적결과평균수술시간은골반림프절절제술을시행하지않은환자 (n=59) 에서 249±58분이었으며, 초기군 (n=29) 에서 330± 75분, 후기군 (n=13) 에서는 207±45분으로통계적으로유의하게수술시간이단축되었다 (p<0.001). 골반림프절절제 술을시행한환자 (n=44) 에서는 281±63분이었고, 초기군 (n=6) 은 378±84분, 후기군 (n=24) 은 240±51분으로초기군과비교하여후기군에서유의하게수술시간이단축됨을보였다 (p<0.001)(table 2). 또한현재에도지속적으로수술시간은감소하는경향을보이고있다 (Fig. 1). 조직학적병기에따른평균수술시간은 T2 이하인군 (n=77) 에서 251±53분, T3 이상인군 (n=26) 에서는 287±92분으로고병기군에서수술시간이길었다 (p=0.031). 수술중의합병증은총 32예 (31.1%) 에서발생하였고초기군에서 21예, 후기군에서 4예로초기군과비교하여유의하게감소하였다 (p=0.009). 술중개복수술로의전환은초기군에서 3예, 중기군에서 1예가발생하였는데, 이는방광요도문합이어려워서수술시간이지연됨에따라빠른수술을위해개복을하였다. 수혈을시행한경우는총 21예로 Table 2. Operative data of extraperitoneal laparoscopic radical prostatectomy All groups Group 1 Group 3 p value Mean operative time (min) PNLD(+) 281±63 373±84 240±51 <0.001* PLND( ) 249±58 330±75 207±45 <0.001* Mean blood loss (ml) 451.5± ± ± * Operating complication Total Open conversion Obturator nerve injury Bladder injury Ureteral injury Rectal injury Transfusion PLND, pelvic lymph node dissection. *Student's t-test; chi-square test. Fig. 1. Legend duration of extraperitoneal laparoscopic radical prostatectomy with pelvic lymph node dissection (A), without pelvic lymph node dissection (PNLD) (B).

4 정호석외 9 인 : 복막의복강경하근치적전립선적출술 173 초기군에서 14예, 후기군에서는 4예로통계적으로유의한감소를보였다 (p=0.021)(table 2). 총 29예 (28.1%) 에서술후합병증이관찰되었고, 이중초기군에서 15예, 후기군에서 3예로초기군에비해유의하게감소하였으며 (p=0.016), 평균요도카테터유치기간과평균재원일수는각각 13.8±2.7일, 10.6±3.6일이었는데, 모두초기군과후기군사이에유의한차이를보이지는않았다 (p>0.05)(table 3). 2. 종양학적결과최종병기는 pt2가 77예 (74.8%), pt3가 25예 (24.3%), pt4가 1예 (0.9%) 였으며 Gleason 점수는 6점이하는 39예 (37.9%), 7점은 34예 (33.0%), 8점이상은 30예 (29.1%) 였으며임상병기와비교하여병기가같거나높게나오는경향을보였다 (Table 4). 절제연양성은총 27예 (26.2%) 에서발생하였는데이중초기군에서 11예 (31.4%) 에비하여후기군에서 9예 (25.7%) 로감소한양상을보였지만통계적으로유의하지는않았다 (p=0.457). PSA 재발은수술 6개월째로초기군과중기군을비교하였는데각각 3예 (8.6%), 2예 (6.0%) 로유의한차이는없었다 (p=0.231)(table 5). 3. 기능적결과 요자제는수술 6개월내에초기군에서 35예중 28예 (80.0%), 중기군은 33예중 26예 (78.8%) 에서가능하였고, 성행위가가능한환자는초기군에서 16예 (45.7%), 중기군에서 16예 (48.5%) 로각각통계적으로의의있는결과를보이지않았다 (p>0.05)(table 5). Table 5. Oncologic & functional results at postoperative 6 months Group 1 Group 2 p value* PSA relapse (%) 3 (8.6) 2 (6.0) Urinary continence (%) 28 (80.0) 26 (78.8) Sufficient erection for 16 (45.7) 16 (48.5) sexual coitus (%) *chi-square test. 고 복강경하근치적전립선적출술은복막을통한접근방법 찰 Table 3. Postoperative data of extraperitoneal laparoscopic radical prostatectomy All groups Group 1 Group 3 p value Mean hospital stay (day) 10.6± ± ± * Mean catheter keep state (day) 13.8± ± ± * Postoperative complication Total Urine leakage Urethral stricture Ileus Port site bleeding Subcutaneous emphysema Acute urinary retention No. of positive surgical margin (%) 27 (26.2) 11 (31.4) 9 (25.7) *Student's t-test; chi-square test. Table 4. Pathologic results of extraperitoneal laparoscopic radical prostatectomy All groups Group 1 Group 2 Group 3 Pathologic Gleason score (%) 6 39 (37.9) 16 (45.7) 10 (30.3) 13 (37.1) 7 34 (33.0) 8 (22.9) 13 (39.4) 13 (37.1) 8 30 (29.1) 11 (31.4) 10 (30.3) 9 (25.7) Pathologic stage (%) T2 77 (74.8) 27 (77.1) 24 (72.7) 26 (74.3) T3 25 (24.3) 8 (22.9) 9 (27.3) 8 (22.9) T4 1 (0.9) 0 (0) 0 (0) 1 (2.8)

5 174 전남의대학술지제 46 권제 3 호 2010 (transperitoneal laparoscopic radical prostatectomy; TLRP) 과복막외접근을통한방법 (extraperitoneal laparoscopic radical prostatectomy; ELRP) 으로시행할수있다. TLRP 는복막을통한수술이므로수술공간의조기확보등의장점이있지만잠재적인복강내합병증을초래할가능성이있고, ELRP는수술공간확보및방광이동성의제한, 정낭박리의어려움등이있지만비뇨기과의사에게익숙한 Retzius 공간, 방광경부, 전립선및골반림프절로의직접적인접근으로수술시간을단축할수있으며복강내관련장기의합병증이발생할확률이적은장점이있다. 12,13 이러한술기상의여러장점에대한보고로최근에는복막외접근을통한시술이증가하고있는추세이다 복강경하근치적전립선적출술은시행초기에는술중과도한출혈, 주변조직과의유착, 방광요도문합등이어려워개복으로전환한경우가있었다고보고되었다. 2,3 저자들의경우에서도초기에기존과달리복막외접근을통한방법의어려움으로인해 4예에서방광요도문합과출혈로인한수술시간지연등으로개복수술로의전환을시행하였으나이는접근방법의특성상술기의어려움으로초기에만발생하였으며경험이축적되면서이로인해개복한경우는없었다 (Table 2). 전립선적출술에서의출혈은배부정맥총과전립선혈관경을처리할때주로발생하며관혈적근치적전립선적출술의경우약 10% 정도에서수혈이필요하다고하였으나, 14 LRP 에서는출혈이발생하면수술시야가나빠지고, 술기가어려워지므로지속적으로지혈을시행하고, 기복하에서수술을시행하므로작은출혈을압박하는효과가있어출혈량이적어졌으며, 대부분의 LRP보고에서출혈량과수혈량이감소함을확인할수있다. 13,15,16 저자들의경우에서도기존의복막을통한접근방법의결과보고에서와유사하게초기군에서개복수술로전환한경우를제외하고는수혈이필요한경우는드물었다 (Table 2). LRP 중자주발생할수있는심각한합병증인직장의손상은해부학적으로전립선과직장이인접해있어직장방광사이막을박리할때에생길수있다. Guillonneau 등 17 은 1,000예의 LRP 중에약 13예의직장손상을보고한바있으며, Katz 등 18 에의하면장루의설치없이손상부위를두층으로교정하며항생제를사용하여장루없이도일차적인교정이가능하다고하였다. 저자들의경우, 3예에서직장손상이발생하였으며모두외과의도움으로교정하였다 (Table 2). 그러나직장손상외에 ELRP에서 TLRP의경우보다장폐색, 복막염및장 손상등의복강내관련장기의합병증의발생률은드물며본연구에서도이를확인할수있었다 (Table 2, 3). 방광요도문합은수술방법과상관없이근치적전립선적출술을시행하는데가장어려운시술중의하나이며술후장기간의요도카테터유치는이에따른감염, 방광자극증상을초래할수있다. 관혈적근치적전립선적출술의경우약 2 3주간의요도카테터유치가필요하나, 19 복강경수술의경우술후 1주일안에제거할수있다고보고한바있다. 20 이는수술시야의개선으로정확한문합이가능하여도뇨관유치기간이짧은것이라고생각되며, 저자들의경우몇차례술후 1주일안에요도카테터를제거를시도하였으나요누출이있는경우가있어방광요도문합을정확하게시행한경우에서도 1주일이상유치하였다 (Table 3). 이는초기에복막외접근방법으로인한수술공간의확보및방광이동성의제한등에의한것으로생각되며수술시행횟수가증가함에따라유치기간을줄일수있었다. 복강경하근치적전립선적출술의종양학적결과는절제연양성과 PSA 재발로평가할수있다. 개복수술의경우보고에따라 16 48% 로보고되고있으며, 21,22 복강경을이용한경우 11 40% 까지다양하게보고되고있다. 15,16,23,24 복강경수술의절제연양성률은개복술과비교하였을때큰차이를보이지않고있으며, 술기의발달과경험이축적되면더욱감소할것으로예상된다. 25 복막외접근을통한저자들의경우에절제연양성률은 26.2% 로, 병리학적병기가높을수록절제연양성률이증가하였으며기존의다른시술방법과큰차이를보이지않았다 (Table 3). PSA 재발은개복근치적전립선적출술후 1년, 5년, 10년후에각각 5%, 20%, 30% 로발생하며, 복강경을이용한경우약 3년간의추적관찰기간동안개복수술과큰차이가없음이보고되었다. 26 저자들의경우초기군에서 6개월후에약 8.6% 에서 PSA 재발이관찰되었지만추적관찰기간이충분하지않아한계가있으며향후지속적인추적관찰이필요할것이다 (Table 5). 요자제는개복근치적전립선적출술은수술시행 1년후 65 95% 로다양하게보고되며, 복강경수술에서도 40 96% 로유사한결과를보이고있다. 13,26-28 저자들의경우 6 개월후의요자제는약 80% 정도로관찰되었다 (Table 5). 그러나요실금의정의및평가방법등이각기다르며동반질환에의하여영향을미칠수있기때문에술후요실금의회복을정확하게평가하기는어려울것으로생각된다. 또한발기능도정의에따라약간의차이는있으며개복근치적전립선적출술후에는 18 68% 로보고되었고, 27,28 복막을

6 정호석외 9 인 : 복막의복강경하근치적전립선적출술 175 통한방법의경우에양측신경을보존한경우술후발기능은 33 85% 로보고되었다. 23,26 복막외접근방법인저자들의경우에 6개월후의발기능은약 45% 정도로관찰되었다 (Table 5). 이는충분한추적관찰이필요하나현재까지복막을통한수술방법과차이를보이지않으며경험이축적되면발기능은더욱향상될것으로기대된다. 저자들의경우에요자제및발기능의기능적결과는추적기간이충분하지않아후기군에대한분석을하지못한한계는있으나지속적인추적관찰중이며, 수술횟수가증가함에따라술후기능적결과는보다향상될것으로생각한다. 복막외복강경하전립선적출술에서저자들은시행초기에는 9시간이상소요된경우도있어개복으로전환하기도하였으나수술기구의발달과수술경험이축적되면서수술시간이지속적으로짧아지고있으며, 향후에도수술시간은더욱단축될수있을것으로기대되어현재까지는정확한학습곡선을정의하기는어렵다. 기존의연구에서학습곡선은다양한방법으로보고되었으나, 3,29 아직까지도이에대한정확한정의나표준화된방법은없는실정이며, 일반적으로그기준은기존의보편화된방법과비슷한수술결과를보이는상태를말하고있어저자들에따라주관적, 객관적인다양한상황에의하여차이를보일수있을것으로생각한다. 복막외복강경하근치적전립선적출술은경복막접근방법과같이장기간의학습시간과노력이필요하나수술중후합병증이적으며빠른회복이가능하고기능적및종양학적결과도현재까지만족할만하여국소적전립선암의치료에일차적으로고려할수있는수술방법으로생각한다. 또한복막외복강경하근치적전립선적출술에서학습곡선은경험이증가함에따라지속적으로좋아지고있는경향을보이나의미있는시점을구분하기는어려우며정확한학습곡선을정의하기위해서는보다많은장기간의수술결과를통한표준화가필요할것이다. References 1. Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparoscopic radical prostatectomy: initial short-term experience. Urology 1997;50: Guillonneau B, Cathelineau X, Barret E, Rozet F, Vallancien G. Laparoscopic radical prostatectomy: technical and early oncological assessment of 40 operations. Eur Urol 1999;36: Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris technique. J Urol 2000;163: Jang J, Cha SH, Kim DB, Kim JC, Hwang TK. Laparoscopic radical prostatectomy. Korean J Urol 2002;43: Raboy A, Ferzli G, Albert P. Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy. Urology 1997;50: Bollens R, Vanden Bossche M, Roumeguere T, Damoun A, Ekane S, Hoffmann P, et al. Extraperitoneal laparoscopic radical prostatectomy. Results after 50 cases. Eur Urol 2001;40: Stolzenburg JU, Truss MC, Do M, Rabenalt R, Pfeiffer H, Dunzinger M, et al. Evolution of endoscopic extraperitoneal radical prostatectomy (EERPE)--technical improvements and development of a nerve-sparing, potency-preserving approach. World J Urol 2003;21: Rozet F, Arroyo C, Cathelineau X, Barret E, Prapotnich D, Vallancien G. Extraperitoneal standard laparoscopic radical prostatectomy. J Endourol 2004;18: Ruiz L, Salomon L, Hoznek A, Vordos D, Yiou R, de la Taille A, et al. Comparison of early oncologic results of laparoscopic radical prostatectomy by extraperitoneal versus transperitoneal approach. Eur Urol 2004;46: Stolzenburg JU, Rabenalt R, DO M, Ho K, Dorschner W, Waldkirch E, et al. Endoscopic extraperitoneal radical prostatectomy: oncological and functional results after 700 procedures. J Urol 2005;174: Stolzenburg JU, Rabenalt R, Tannapfel A, Liatsikos EN. Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy. Urology 2006;67: Trabulsi EJ, Guillonneau B. Laparoscopic radical prostatectomy. J Urol 2005;173: Eden CG, King D, Kooiman GG, Adams TH, Sullivan ME, Vass JA. Transperitoneal or extraperitoneal laparoscopic radical prostatectomy: does the approach matter? J Urol 2004;172: Kim YJ, Han BK, Byun SS, Lee SE. Comparison of perioperative outcomes of extraperitoneal laparoscopic radical prostatectomy (ELRP) versus open radical retropubic prostatectomy (RRP): single surgeon's initial experience. Korean J Urol 2007;48: Hoznek A, Samadi DB, Salomon L, De La Taille A, Olsson LE, Abbou CC. Laparoscopic radical prostatectomy: published series. Curr Urol Rep 2002;3: Guillonneau B, Rozet F, Cathelineau X, Lay F, Barret E, Doublet JD, et al. Perioperative complications of laparoscopic radical prostatectomy: the Montsouris 3-year experience. J Urol 2002;167: Guillonneau B, Gupta R, El Fettouh H, Cathelineau X, Baumert H, Vallancien G. Laparoscopic [correction of laproscopic] management of rectal injury during laparoscopic [correction of laproscopic] radical prostatectomy. J Urol 2003;169: Katz R, Borkowski T, Hoznek A, Salomon L, de la Taille A, Abbou CC. Operative management of rectal injuries during laparoscopic radical prostatectomy. Urology 2003;62: Ghavamian R, Knoll A, Boczko J, Melman A. Comparison of operative and functional outcomes of laparoscopic radical prostatectomy and radical retropubic prostatectomy: single surgeon experience. Urology 2006;67: Nadu A, Salomon L, Hoznek A, Olsson LE, Saint F, de La Taille A, et al. Early removal of the catheter after laparoscopic radical prostatectomy. J Urol 2001;166: Ohori M, Wheeler TM, Kattan MW, Goto Y, Scardino PT. Prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol 1995;154:

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untitled Prostate Day 2006 경복막접근복강경근치적전립선적출술 성균관대학교의과대학마산삼성병원비뇨기과학교실 오태희 서 론 국소전립선암의수술적치료의목표는암을완전히제거하고요자제나성기능을최대한유지하고그이환율을최소화하는것이다. 최근골반및전립선주위조직의해부학적구조가밝혀지고근치적치골후전립선적출술의술기가발달됨에따라그치료효과가향상되고합병증을최소화할수있게되었다. 동시에복강경수술역시낮은이환율을가진최소침습수술로서인정받아외과영역에서각광받기시작하였다.