Korean Journal of Obstetrics and Gynecology Vol. 53 No. 9 September 2010 요실금수술후발생한배뇨장애의처치 가천의과학대학교산부인과학교실 구천회 황병철 Management of voiding dysfunction after anti-incontinence operation Chun Hoe Ku, M.D., Byung Chul Whang, M.D. Department of Obstetric and Gynecology, Gachon University of Medicine and Science, Incheon, Korea With the increasing number of surgery for incontinence, voiding dysfunction after anti-incontinence surgery will continue to be a problem. The patient with postoperative voiding dysfunction may present with primarily storage symptoms or voiding symptoms, or a combination of both. Detailed knowledge of the preoperative voiding status may aid in the diagnosis of voiding dysfunction. Diagnosis is based on history, physical examination, urinalysis and postvoid residual volume, but additional informations from urodynamic study and cystoscopy are useful. Patients with postoperative voiding dysfunction should be initially treated conservatively with intermittent or continuous catheterization, fluid restriction, anticholinergics and pelvic floor physiotherapy. When conservative treatment fails, surgical intervention should be done. It is important to distinguish between midurethral sling and other procedures because the timing and type of intervention vary. In case of midurethral sling, loosening or cutting the tape has had excellent results. Prevention of obstruction during surgery may be the best way to avoid reoperation. Key Words: Anti-incontinence surgery, Voiding dysfunction 접수일 :2010. 8. 4. 채택일 :2010. 9. 6. 교신저자 : 구천회 E-mail:kchob@gilhospital.com 서론 복압성요실금은주로수술적치료로만족스러운성적을보이며, 수술적치료방법은보다안전하고간편하며효과가우수한방법으로발전해왔다. 1996 년 tension-free vaginal tape (TVT) 와 2001년 transobturator tape (TOT) 가발표된이후, 이수술법들의높은성공률과낮은합병증으로요실금수술건수가급속하게증가하였으며이에따라필연적으로요실금수술과연관된합병증들도증가하고있다. 1-7 요실금수술후발생하는배뇨장애는환자에게추가적인비용을지출하게하고수술만족도를낮추는요인이지 만아직까지진단방법및치료에대해확실하게정립된것이없다. 이에여기에서는요실금수술후발생한배뇨장애의처치에대해알아보고자한다. 증상및정의요실금수술후나타나는배뇨장애는다양한증상으로나타날수있으며, 크게보면저장증상 (storage symptoms) 과배뇨증상 (voiding symptoms) 으로나눌수있다. 저장증상은주로방광자극증상 (irritative symptom) 으로나타나며빈뇨 (frequency), 절박뇨 (urgency), 야간뇨 (nocturia), 절박성요실금 (urge incontinence) 등이있으며, 배뇨증상은주로폐색증상 (obstructive symptoms) 으로나타나며배뇨지연 (hesitancy), 배뇨시복부힘주기 (voiding with abdominal straining), 약한소변줄기 (poor - 761 -
대한산부회지제 53 권제 9 호, 2010 stream), 잔뇨감 (incomplete emptying), 요폐 (urinary retention) 등이있다. 8 그러나이러한임상증상만가지고는실제요실금수술후배뇨장애환자를구별하기는어렵다. Carr와 Webster 9 는요실금수술후배뇨장애로요도박리술 (urethrolysis) 을시행한 51명의환자에서가장흔한증상인자극증상이 75% 의환자에서나타났으며, 지속적인요정체가나타난환자는 24% 였다고보고하였다. 또한 Blaivas와 Groutz 10 도여성방광출구폐색 (bladder outlet obstruction, BOO) 환자의 58% 에서자극증상과폐색증상이같이있으며, 자극증상만을보이는경우도 32% 였으나 폐색증상만보이는경우는오직 10% 에불과하다고하였다. 그러므로요실금수술후배뇨장애의증상을보이는환자들은요류검사및잔뇨량을측정하여배뇨기능을평가해야한다. 아직까지배뇨장애에대한정의나명확한진단기준이정립되지는않았으나, 통상적으로배뇨전방광용적 ( 배뇨량과잔뇨량의합 ) 이최소한 150 ml 이상일때, 최대요속이 15 ml/sec 미만또는잔뇨량이 50 ml 를초과하는경우로정의하거나혹은배뇨량과최대요속의평균치를나타낸 Liverpool nomogram 을이용하여 10 percentile 이하일때로정의한다 (Fig. 1). 11,12 유병률 Fig. 1. Liverpool nomogram for maximum urine flow rate in woman. 요실금수술후배뇨장애의유병률은진단기준및수술방법에따라다양하게보고되고있다. 1997 년미국비뇨기과학회 (American Urological Association) 에서 1994 년 1 월까지시행된요실금수술 282 편의논문을분석하여발표한자료에따르면, 4주이상지속되는요폐가치골뒤걸이술 (retropubic suspension) 은 3~7%, 경질걸이술 (transvaginal suspension) 은 4~8%, 슬링시술 (sling procedure) 은 6~11% 로보고하였으며, 영구적인요폐는세시술모두 Table 1. Voiding dysfunction after mid-urethral sling procedures Reference Procedure No. of patients Retention requiring Retention requiring catheterization (%) tape transaction (%) De novo urgency Abouassaly et al. 15 TVT 241 19.5 4.15 13.6 Deval et al. 16 TVT 187 10.7 3.7 21.3 Haab et al. 17 TVT 62 4.8 1.6 6.4 Jeffry et al. 18 TVT 112 8.9 2.7 25.9 Karram et al. 19 TVT 350 4.9 1.7 NR Kuuva et al. 20 TVT 1,455 2.3 NR 0.8 Levin et al. 21 TVT 313 2.5 0.3 8.3 Nilsson et al. 22 TVT 90 0 0 5.9 Rezapour et al. 23 TVT 80 4.8 1.6 6.4 Andonian et al. 24 SPARC 41 4.9 4.9 NR Deval et al. 25 SPARC 129 10.5 2.8 11.5 Gandhi et al. 26 SPARC 49 10 2 24 Hodroff et al. 27 SPARC 445 6.6 4.3 6.1 Costa et al. 28 TOT 183 2.2 1.6 2.2 Davila et al. 29 TOT 200 2.0 0.5 0 Delorme et al. 30 TOT 32 3.1 NR 15.6 Deval et al. 31 TOT 129 5.4 1.5 9.3 Spinosa and Dubuis. 32 TOT 117 NR NR 2.5 TVT: tension-free vaginal tape, SPARC: suprapubic arc, TOT: transobturator tape, NR: none reported. - 762 -
황병철외 1 인. 요실금수술후발생한배뇨장애의처치 5% 이하일것이라고하였다. 13 Dunn 등 14 은 1966 에서 2001 년까지수술후배뇨장애 (postoperative voiding dysfunction) 에관한논문을분석한결과 Burch 질걸이술 (colposuspension) 은 4~22%, Marshall-Marchetti-Kranz 시술은 5~20%, 침걸이술 (needle suspension) 은 5~7%, 치골질슬링 (pubovaginal sling) 은 4~10%, TVT 는 24% 의배뇨장애를보였다고하였다. 최근널리이용되는 TVT, TOT 등의중부요도슬링 (mid-urethral sling) 의경우이론적으로중부요도에장력없이 (tension free) 테이프를유치함으로써기존의수술보다배뇨장애의빈도가현저히감소될것으로기대되었으나, 여전히다양하게배뇨장애가보고되고있다 (Table 1). 15-32 수술후새로생기는절박뇨 (de novo urgency) 의경우치골뒤걸이술은 8~16%, 경질걸이술은 3~10%, 슬링시술은 3~11%, TVT는 1~25%, TOT 는 0~15% 로보고되고있다. 한편, 수술전에절박뇨증상을가지고있는환자는수술후에도절박뇨증상을가질가능성이높으며, 치골뒤걸이술의경우 36~66%, 경질걸이술은 54%, 슬링시술은 34~46% 로요실금수술후절박뇨증상이지속된다고한다. 13 기전모든요실금수술의성공을위해서는어느정도의출구저항 (outlet resistance) 의증가가필요하다. 그러나출구저항의증가는복압이증가하는상황에서만뚜렷하게나타나야하며배뇨중에는최소한으로유지되어야한다. 요실금수술후배뇨장애의기전은수술의종류에따라서다를수있다. 치골뒤또는경질걸이술의경우외측요도옆조직을안정화시키므로방광경부의과들림 (hyperelevation) 이나근위부요도의꼬임 (kinking) 으로인하여폐색이나타날수있다. 반면, 슬링수술의경우슬링재료의장력의증가로인하여직접적으로요도를압박하여발생하며, 대부분은수술시장력조절의실패로인한과도한견인때문이며슬링재료와주위조직간에협착이진행되어당겨져서발생할수도있다. 8 중부요도슬링수술의경우무장력으로시술되지만배뇨시어느정도의요도압박은발생한다고한다. Lukacz 등 33 은 TVT 수술을받은 65명의환자의수술전과수술 1년후배뇨증상과요역동학검사를비교하였을때, 주관적인배뇨증상은변화가없었으나수술전최대요속은 28.6 ml/sec, 수술 1년후에는 16.3 ml/sec 로유의하게감소하였으며배뇨시간은 29.1 초에서 42.6 초로유의하게증가하는것으로보고하였다. TOT 수술의경우유치된테이프의각도가 TVT 보다완만하여요도압박이적을것이라생각되나, Barry 등 34 은 TOT 수술을받은 83명의환자를대상으로한전향적인연구에서수술전에비하여수술 6~8 주후최대요속이유의하게감소한다고보고하였다. 진단요실금수술후배뇨장애의진단을위해서는먼저수술전배뇨상태에대한자세한정보가도움이될수있다. 수술전저장및배뇨증상의유무, 잔뇨량등의정보가유용하게사용될수있으며요역동학검사를시행했다면다시한번검토해보아야한다. 만일수술전배뇨기능이정상인환자가수술후잔뇨감혹은요폐가발생하였다면이는 BOO 의가능성을강하게시사할수있다. 요실금수술후배뇨장애의진단을위해서는철저한병력청취가중요하다. 수술후빈뇨, 절박뇨, 야간뇨, 절박성요실금등의저장증상만있는지또는배뇨지연, 약한소변줄기, 잔뇨감, 요폐등의배뇨증상만있는지또는두증상이같이있는지확인하여야하며, 수술후증상이언제나타났는지얼마나지속되었는지도확인하여야한다. 그후이학적검사를시행하여방광경부의과들림여부를관찰하고기침유발검사를통해복압성요실금여부를관찰하고방광질누공여부도확인해야한다. 골반장기탈출이새로발생했는지, 기존에골반장기탈출이있었다면더심해졌는지도관찰해야한다. 지속적인저장증상을가진환자들은방광경검사를시행하여슬링재료및봉합사에의한방광천공, 요도미란 (urethral erosion) 을배제해야하며방광질누공, 중부요도또는방광경부의과들림, 요도협착등을관찰해야한다. 폐색증상이있는환자들은선별검사로서요류검사및잔뇨량을측정한다. 배뇨장애는앞서기술한기준에따라판정하나, 요류및잔뇨량검사로는압력에대한정보를제공할수없어비정상적인결과를보이는경우배뇨근수축력의감소에의한것인지아니면방광출구폐색에의한것인지감별할수없다. 35 그러므로요류및잔뇨량검사에서배 - 763 -
대한산부회지제 53 권제 9 호, 2010 Free Qmax (ml/sec) Fig. 2. Bladder outlet obstruction nomogram for woman. 뇨장애가의심되는경우압력요류검사 (pressure-flow study) 를시행하여야한다. 압력요류검사에서요속의감소와배뇨근압의상승이나타날경우 BOO 를의심해야한다. 현재까지 BOO 에대한표준화된진단기준이없이여러기준이제시되고있으나, 대부분최대요속 (Qmax) 은 11~15 ml/sec 이하그리고최대요속시배뇨근압 (PdetQmax) 은 20~25 cmh 2 O 이상일경우로진단기준을제시하고있다. 36-38 한편, Blaivas 와 Groutz 10 는압력요류검사에서의요류검사와최대요속시배뇨근압을사용하지않고비침습적인요류검사와최대배뇨근압을이용한 nomogram 을여성 BOO 의진단기준으로제시하였다 (Fig. 2). 그들은경요도카테터가요속의감소에영향을주기때문에압력요류검사시실제보다 BOO 환자가증가할수있다고하였으며, 경요도카테터의영향을피할수있는비침습적최대요속 (free Qmax) 과최대배뇨근압 (Pdet.max) 을이용하여 BOO 를정도에따라서경도 (mild), 중등도 (moderate), 고도 (severe) 로구분하였다. 들은우선적으로수분제한, 항콜린성약제, 골반근육운동등의치료를한다. 이런보존적치료에도불구하고지속적으로저장증상이있다면요역동학검사및방광경검사를시행하여 BOO 를배제하는것이중요하다. 만약 BOO 가존재한다면슬링절단 (incision) 이나요도박리술등을고려해야한다. 일부에서는 Hegar 확장기를이용하여요도와요도주위를이완하는요도확장술 (urethral dilatation) 을시행하여배뇨증상이호전되었다는보고가있으나, 연구가제한적이며또한무리하게시행될경우요도에손상을줄수있으므로주의를기울여야한다. 19,39 2. 수술적방법 (Surgical intervention) 수술적방법은배뇨장애가 BOO 에의한원인으로보존적치료에호전되지않을때시행하게된다. 수술적치료는수술시기와방법이다양하므로이전에어떤종류의요실금수술을하였는지구분하는것이중요하다. 40 중부요도슬링의경우대개수술적치료가보다빨리시행되며덜침습적이나, 치골질슬링, 경질걸이술, 치골뒤걸이술의경우대개수개월후에수술적치료가시행되며수술방법도침습적인경우가많다. 수술방법의경우이전수술이치골뒤걸이술이었던경우에는치골뒤요도박리술이주로시행되며, 치골질슬링의경우경질슬링절단또는경질요도박리술이시행되며, 중부요도슬링의경우슬링의이완또는절단이시행되며각각의수술성적은다음과같다 (Table 2). 41-56 치료 1. 보존적방법 (Conservative management) 잔뇨량증가및요폐등배뇨증상을주로호소하는환자는간헐적혹은지속적자가도뇨를하며증상의호전을기다려볼수있다. 소수의환자에서는재수술에대한두려움과요실금재발에대한걱정으로보존적인치료를선호하나, 보존적인치료로배뇨증상이해결되지않는환자들은대부분수술적인방법을선택하게된다. 저장증상을주로호소하나정상적으로배뇨를하는환자 1) 중부요도슬링이완또는절단 (Midurethral sling loosening or incision) 중부요도슬링의경우수술후대부분의환자들이 72시간이내에정상적인배뇨가가능하므로 BOO 가의심되는경우초기에치료하는것이선호된다. 초기치료는대부분 2주이내에이루어지며외래에서국소마취하에시행된다. 이전절개부위를통해테이프를찾은후 right angle clamp 를이용하여테이프를요도아래쪽으로내려주며 1~2 cm 정도이완시킨다. 54 수술후 2주이상지난경우에는조직이테이프내로내증식 (ingrowth) 하게되어테이프를절단하는경우가많으며보다광범위한박리가필요하므로수술실에서 - 764 -
황병철외 1 인. 요실금수술후발생한배뇨장애의처치 Table 2. Summary of series on sling loosening/incision and urethrolysis for obstruction after incontinence surgery Reference No. of patients Delay to urethrolyis (month) Type of urethrolysis Success (%) Recurrent SUI (%) Zimmern et al. 41 13 42 Transvaginal 92 0 Foster and McGuire. 42 48 26 Transvaginal 65 0 Nitti and Raz 43 42 54 Transvaginal 71 2 Cross et al. 44 39 11 Transvaginal 100 (retention) 3 86 (urge sx) Goldman et al. 45 32 14 Transvaginal 84 19 Carey et al. 46 23 14 Transvaginal with Martius flap 87 13 Petrou et a.l 47 32 NR Suprameatal 67 3 Webster and Kreder 48 15 8 Retropubic 93 13 Petrou and Young 49 12 19 Retropubic 83 18 Carr and Webster 9 51 15 Mixed 78 14 Amundsen et al. 50 32 10 Transvaginal and sling incision 94 (retention) 9 67 (urge sx) Nitti et al. 51 19 10.6 Sling incision 84 17 Goldman. 52 14 8.6 Sling incision 93 21 Thiel et al. 53 13 2.2 Sling incision 92 8 Klutke et al. 54 17 2.1 TVT incision or loosening 100 6 Rardin et al. 55 23 2 TVT incision 100 (retention) 39 30/70 (urge sx cure/improve) Long et al. 56 7 0.9 Lateral TVT incision 86 28 SUI: stress urinary incontinence, NR: none reported, TVT: tension-free vaginal tape. 시행하는것을고려해야한다. 테이프의이완또는절단후비교적좋은성적이보고되는데 Klukte 등 54 은 TVT 수술후 BOO 로테이프의이완또는절단한 17명의환자모두폐색증상이완치되었으며, 요실금이재발된경우는 1명이었다고하였다. Rardin 등 55 은 TVT 수술후지속적인배뇨장애를보인 23명의환자에게테이프절단을시행했으며 6주후에모든환자에서폐색증상은없어졌으며, 자극증상의경우 30% 는완전히없어졌으며 70% 는호전되었고, 요실금의재발은 13%, 부분재발은 26% 라고보고하였다. 2) 경질슬링절단 (Transvaginal sling incision) 경질슬링절단의경우중부요도슬링보다더오랜기간이지난후에시행되며보다광범위한박리가필요하다. 전신마취혹은부위마취 (regional anesthesia) 가필요하며수술전과수술후에방광경을시행하여방광및요도의미란및손상을확인해야한다. 요도박리술보다신경및연부조직의손상이덜하고박리후섬유화 (fibrosis) 가덜하기때문에우선적으로고려해야하며, 84~93.5% 의성공률이보고되며요실금의재발은 8~21% 정도이다. 50-53 경질슬링 절단으로슬링이완전하게제거가안되거나폐색증상이지속되는경우요도박리술을시행하여야한다. 3) 경질요도박리술 (Transvaginal urethrolysis) 전질벽에중앙혹은역 U자 (inverted U) 절개를한후외측으로요도주위조직을따라서내골반근막 (endopelvic fascia) 을천공한후치골뒤공간까지접근한뒤요도가치골하부로부터자유로운움직임을갖도록박리한다. 57 수술전과후에방광경을시행하며대개는수술전에요도와방광경부가고정되어있고이동성 (mobility) 이없다가요도박리술후에는이동성이복구된다. 요도주위에유착이심하거나반복되는요도박리술의경우치골하부와요도사이에 Martius labial fat flap 을사용하기도하며이는재발성유착을감소시키며요도를지지하는역할을하고요도손상을감소시키는역할을한다. 46 4) 치골뒤요도박리술 (Retropubic urethrolysis) 질식접근이불충분할때, 이전수술이치골뒤걸이술인경우, 경질요도박리술시행시방광천공, 누공등의합병 - 765 -
대한산부회지제 53 권제 9 호, 2010 증이발생한경우시행한다. 48,49 결론최근요실금수술의증가에따라수술후배뇨장애의보고도늘어나고있다. 요실금수술후배뇨장애의증상은방광자극증상및폐색증상으로다양하게나타날수있으며진단을위해서는수술전환자의배뇨상태를파악하는것이도움이된다. 요실금수술후배뇨장애가발생한경우자세한병력청취, 이학적검사, 잔뇨량검사를시행하며필요에 따라서요역동학검사, 방광경검사를시행하여야한다. 치료로는우선자가됴뇨, 수분제한, 항콜린성약제, 골반근육운동등의보존적치료를시행하며효과가없을경우수술적치료를한다. 이전요실금수술에따라서수술시기및방법이달라지나최근중부요도슬링의경우빠른시기에테이프를이완하거나절단하는방법으로좋은성적이보고되고있다. 요실금수술후배뇨장애를예방하는가장좋은방법은수술시과도한장력을피하는것이므로, 항상이를염두에두고수술을시행하여야하겠다. 1. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 81-5. 2. de Leval J. Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out. Eur Urol 2003; 44: 724-30. 3. Nilsson CG, Palva K, Rezapour M, Falconer C. Eleven years prospective follow-up of the tension-free vaginal tape procedure for treatment of stress urinary incontinence. 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대한산부회지제 53 권제 9 호, 2010 = 국문초록 = 최근요실금수술이증가함에따라수술후배뇨장애가문제가되고있다. 요실금수술후배뇨장애를가진환자는주로저장증상또는배뇨증상이나타나며진단을위해서는수술전환자의배뇨상태를파악하는것이도움이된다. 요실금수술후배뇨장애의진단은병력청취, 이학적검사, 요검사, 잔뇨량검사를기초로하며요역동학검사, 방광경검사를이용한정보도유용하다. 치료로는우선자가됴뇨, 수분제한, 항콜린성약제, 골반근육운동등의보존적치료를시행하며효과가없을경우수술적치료를한다. 이전요실금수술이중부요도슬링인지다른시술인지에따라서수술시기및방법이달라지므로이를구별하는것이중요하다. 최근중부요도슬링의경우빠른시기에테이프를이완하거나절단하는방법으로좋은성적이보고되고있다. 요실금수술후배뇨장애를예방하는가장좋은방법은수술시과도한장력을피하는것이므로, 항상이를염두에두고수술을시행하여야하겠다. 중심단어 : 요실금수술, 배뇨장애 - 768 -