대한배뇨장애요실금학회지 J Korean Continence Soc 29;13:121-7 원저 65세이상복압성요실금환자에게시행된 Canal transobturator tape수술법의예비보고 성균관대학교의과대학강북삼성병원산부인과학교실웰빙케어링센터 최경미 이세진 이정훈 최중섭 김계현 한종설 이교원 Preliminary report of Canal Transobturator Tape for Stress Urinary Incontinence in Women Over 65 Years Kyung-Mi Choi, Se-Jin Lee, Jung-Hun Lee, Joong-Sub Choi, Kye-Hyun Kim, Jong-Sul Han, Kyo-Won Lee Wellbeing Caring Center, Division of Urogynecology, Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea Purpose: To access the feasibility of Canal transobturator tape (Canal TOT) for stress urinary incontinence (SUI) in women over 65 year old. Materials and Methods: From August 26 to December 28, we reviewed the medical records of 261 patients underwent Canal TOT in Division of Urogynecology, Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine in Seoul. This study is a retrospective analysis of the clinical characteristics (age, gravida, parity, body mass index), previous operation history, comorbidity, surgical procedure and operation outcomes. We performed stress test, one hour pad test, urodynamic study, postvoid residual assessment to all patients for diagnosis of SUI. All patients answered self assessment questionnaires (IIQ-7, UDI-6) at 6 months and 12 months after operation. Results: 55 women over 65 years were underwent Canal TOT. Mean follow up was 11±4.5 months. Mean age of patients was 7.2±3.9 years, gravida 5.8±2.3 times, parity 3.9±1.5 times and body mass index (BMI) 25.6±3.1Kg/m 2. 8 patients had got hysterectomy (14.5%). 16 patients (29%) had sling operation (Canal TOT alone), and 39 patients (71%) had Canal TOT combined with vaginal surgery for pelvic organ prolapse. The cure rate was 96.4% in 6 months follow up. Leakage after operation were reported by 2 patients (3.6%) and 3 patients (5.5%) transiently suffered from postoperative voiding difficulty. Of whom had incontinence complexed with overactive bladder symptoms (frequency, nocturia, and urgency) 12 patients complained of persistent symptoms after Canal TOT (12/33, 36.4%). 1) 접수일자 : 29 년 12 월 4 일, 수정일자 : 29 년 12 월 16 일, 채택일자 : 29 년 12 월 23 일교신저자 : 이교원, 성균관대학교의과대학산부인과학교실서울시종로구새문안길 78 ( 서울시종로구평동 18 번지 ) 우 11-746 Tel: 2-21-2194, Fax: 2-21-2187, E-mail: kw4773.lee@samsung.com Vol. 13, No. 2, 29 121
최경미 이세진 이정훈 최중섭 김계현 한종설 이교원 The scores from self assessment questionnaires (IIQ-7, UDI-6) at6months after operation were improved significantly. Conclusion: Canal TOT is feasible and safe method for SUI in old age. The procedure also shows favorable results when combined with other operations for pelvic organ prolapse. (J Korean Continence Soc 29;13:121-7) Key Words: Urinary incontinence, Canal transobturator tape 서론요실금은모든불수의적요누출로정의되며그증상의범위와원인이다양하지만특히중년이후의여성에서발생빈도가높고나이에따라조금씩증가한다 [1,2]. 복압성요실금의경우한국여성에게서 24% 정도로나타나고있다. 요실금은노화에따른변화로서받아들여지고있으나분만횟수, 비만, 약물복용, 인지장애등이영향을미치는것으로알려져있다. 요실금의종류는 8 9% 를차지하는복압성요실금외에도절박성요실금, 그리고두증상이함께나타나는혼합성요실금이있으며일류성요실금 (overflow incontinence) 이나타나는환자도있다. 고령환자가요실금을호소하는경우기저질환과약물복용력, 인지장애, 요로감염증여부를우선확인해야하며, 나이가듦에따라골반장기탈출증이발생하여요실금과함께나타나는경우도흔하다 [3]. 복압성요실금의치료법으로 tension free vaginal tape (TVT) 이소개된이후에최소침습수술기법들이다양하게제시되고있으며최근에는 transobturator tape (TOT) 가편리성과높은치료효과로인해널리이용되고있으나방광천공, 요로손상과같은심각한합병증의발생이계속보고되고있다 [4]. 본원비뇨부인과에서는 Raz 등이제시한 distal urethral polypropylene sling (DUPS) [5] 수술법과기존의 TOT수술법을접목하여 Canal Transobturator tape (Canal TOT) 슬링수술을새롭게고안하였으며, 1년간의임상경험을토대로 Canal TOT 수술법은특히 vaginal surgery 기왕력이있 는환자, 비만, paravaginal defect로인한방광류 (cystocele) 가있는환자에서더욱안전하고합병증을최소화할수있다고보고한바있다 [6]. 본연구는고혈압, 당뇨등기저질환과고도의골반장기탈출증이흔하게동반되는 65세이상의고령환자에서안전하고효과적인복압성요실금치료법으로서 Canal TOT수술법의효용성 (feasibility) 을조사하였다. 대상및방법 26년 8월부터 28년 12월까지성균관대학교의과대학강북삼성병원산부인과에서 Canal TOT [6] 수술을받은 261명의환자들의의무기록을후향적으로분석하여 65세이상환자들의임상적특성과수술및수술이후의경과를조사하였다. 환자들은복압성요실금진단을위해병력청취, 이학적검사, 요검사, 요배양검사, 잔뇨량측정, 배뇨일지, 기침유발검사 (stess test), 1시간 pad test 및요역동학검사를받았다. 수술후 1, 6, 12개월에기침유발검사 (stress test), 1 hour pad test 및잔뇨량검사를시행하여치료경과를확인하였으며 6, 12개월에설문지 (Incontinence Impact Questionnaire-short form IIQ-7, Urogenital Distress Inventory-short form UDI-6) 를통해치료효과를확인하였다 [7]. 수술후치료 (Cure) 여부는환자가요실금증상호소가없고기침유발검사에서요누출이없는경우로정의하였다. 배뇨곤란증상이있는경우수술후 6주이내에증상이호전된경우를일과성배뇨곤란으로분류하였다. 122 대한배뇨장애요실금학회지
65 세이상복압성요실금환자에게시행된 Canal transobturator tape 수술법 Operative Techniques 환자에게전신혹은부위마취를시행한다. 환자의자세를앙와쇄석위로하고고관절을 9 굴곡시킨자세로다리를고정한다. 포비돈요오드로수술부위를소독하고 16Fr Foley 도뇨관을삽입한다. 요도구 1cm 하방의질전벽을 3개의 Allis clamp를이용하여고정한후질전벽에양측면을따라사선으로 1.5cm 길이의절개선 2개를넣는다. 두절개선사이로요도와 urethropelvic ligament 사이에 suburethral canal을만든다. 이때 canal은요도와 urethropelvic ligament 사이에위치해야한다. monofilament polypropylene tape를 canal 안쪽으로통과시킨다. 질전벽절개선측면에서질벽과 urethropelvic ligament 사이를박리하여검지로 ischiopubic ramus 후연과폐쇄공막을확인한후 clitoris 높이의양쪽대퇴주름 (genitocrural fold) 에서수지유도하에 tunneler를폐쇄공막으로통과시키고테이프를빼낸다. 질전벽절개선사이로 Allis clamp를이용하여 mesh를고정하고슬링의장력 (tension) 을조절한다 (adjustment). 대퇴주름 (genitocrual fold) 의찌름절개 (stab incision) 부위는국소피부접착제 (topical skin adhesive, DERMABOND R ) 를이용하여봉합하고질전벽절개는 3- 흡수봉합사를이용하여봉합한다. 질충전 (vaginal packing) 한거즈와도뇨관은수술후 1일째에제거하고배뇨후잔뇨량을측정한다. 방광류복원술을함께시행한경우 3일간도뇨관을유지한다. SPSS15.을사용해 Pearson Chi-square test를실시하여통계치를구하였다. P<.5인경우를통계적유의성이있는것으로판단하였다. 결과 26년 8월부터 28년 12월까지 Canal TOT 수술을받은 65세이상환자는 55명이었다. 평균나이는 7.2±3.9세, 평균임신력 5.8±2.3회, 평균분만력 3.9±1.5회였다. 체질량지수는 25.6±3.1kg/m 2 였으며기저질환이있는환자는 32명 (58.2%), 이전에자궁적출술을받았던환자는 8명 (14.5%) 이었다. 슬링수술만을 받은환자는 16명 (29%) 이었고골반장기탈출증수술을함께받은환자는 39명 (71%) 이었다. 평균추적관찰기간은 11±4.5개월이었다. 평균수술시간은 86±45 분, 평균혈색소치변화는 1.5±1.2mg/dL였다. 수술후방광천공, 요도손상, 혈종, 수술부위감염과같은수술합병증은발생하지않았다 (Table 1-3). 65세이상의복압성요실금환자에게시행된 Canal TOT의치료율은수술후 6개월에 96.4% (53/55) 이며수술후요실금증상이지속된환자는 2명 (3.6%), 수술후일과성배뇨곤란이발생한환자는 3명 (5.5%) 이었다. 요누출이지속된환자 2명중수술전요역동학검사에서요로의내인성괄약근기능부전 (intrinsic sphincter deficiency: ISD) 을나타낸경우는없었다. 요누출이지속된환자중 1명은슬링수술만받았던환자로수술후 2일째에 mesh plication을시행하였고, 현재증상재발없이 24개월간추적관찰중이다. 요누출과빈뇨, 절박뇨를함께호소하던다른환자는슬링수술과방광류및직장류복원술을같이받았으며수술중방광경검사에서방광암 (bladder cancer in situ) 이발견되어비뇨기과로전과되어치료를받았던환자이다. 일상적인기침유발검사에서는요누출이관찰되지않았으나서있는자세에서는요누출이확인되었다. 보존적요법을함께시행하여 3주후요누출증상은호전되었으나빈뇨와절박뇨는약간호전된상태로지속되고요누출은일주일에 2 3회나타나는상태로 3개월간추적관찰중이다. 배뇨곤란을겪었던환자 3 명은모두방광류복원술과직장류복원술을함께받은환자였다. 2명의환자는 1주간의도뇨관유치후자연배뇨가가능해졌으며나머지환자 1명은자연배뇨는가능하였으나 15mL 정도의잔뇨가지속되어청결간헐도뇨 (clean intermittent catheterization: CIC) 가 4 주간필요하였다 (Table 3). 복압성요실금에과민성방광증상 ( 빈뇨, 야간뇨, 절박뇨 ) 이동반된환자들 (33명) 중과민성방광증상이지속된환자는 12명 (36.4%) 이었다. 새롭게발생한절박뇨를호소하는환자는없었으나절박성요실금이동반되었던환자 1명은슬링수술후에도증상이지속되었다. 수술후 6개월째에설문조사형태로삶의질개선효과와수술법의치료효과를평가하였다. 사용한설문 Vol. 13, No. 2, 29 123
최경미 이세진 이정훈 최중섭 김계현 한종설 이교원 Table 1. Clinical characteristics and performed operations Characteristics Mean±SD or No. (%) Age (years) Parity (times) Body mass index (Kg/m 2 ) Previous hysterectomy Comorbid disease 7.2±3.9 3.9±1.5 25.6±3.1 8 (14.5) 32 (58.2) Sling and concomitant operations No. (%) Canal transobturator tape alone Combined with vaginal surgery Cystocele repair Rectocele repair Transvaginal hysterectomy 16 (29) 39 (71) 35 (64) 36 (65) 14 (25) Preoperative accessment Mean±SD or No. (%) Preoperative symptoms of OAB a Detrusor overactivity Cystocele, stage II, III Q tip test ( ) VLPP b (cmh 2O) MUCP c (cmh 2O) Residual urine (ml) a Overactive bladder; b Valsalva leak point pressure; c Maximum urethral closure pressure Mean±standard deviation; number (%) 33 (6) () 35 (64) 33.3±4.5 7.4±16.2 47±27.6 16±17 Table 2. Operative results Operative results Operation time (minutes) Hemoglobin change (mg/dl) Hospital stay (days) Constitutional symptoms Canal TOT a with vaginal surgery (Canal TOT alone) 85.9±45.3 (3.6±11.7) 1.5±1.2 (.8±.9) 5.8±2.6 (3.2±.4) 5 (9) a Canal transobturator tape; Mean±standard deviation; number (%) Table 3. Postoperative complications after Canal transobturator tape Postoperative complications No. (%) Retropubic hematoma Urinary tract infection Voiding difficulty Urinary leakage Vaginal erosion De novo urgency Injury of bladder, urethra, vessel, nerve 3 (5.5) 2 (3.6) 지 IIQ-7, UDI-6 평균점수는각각수술전후 8.4±3.9, 5.6±4.2에서.95±1.7,.15±1.1로나와모두유의하게호전된것으로나타났다 (Table 4). 고찰나이가듦에따라요실금유병률은조금씩증가하는것으로알려져있다 [2]. 요실금을비롯한하부요로증상들은환자의삶의질에영향을미치며사회활동 의제한및정신과질환에도영향을끼치는것으로나타나고있다 [8]. 본연구의대상환자들은모두 65세이상이고증상이평균 8년이상지속된환자들이나기존에복압성요실금수술이나골반장기탈출로인한수술을받은적은없었다. 최근에요실금과골반장기탈출증과같은질병에대해수술적으로적극적인치료를받는경우가증가하고있으며, 최소침습적인수술방법인 midurethral sling operation이주로이용되어높은치료효과를보이고있다 [8,9]. 그러나이러한치 124 대한배뇨장애요실금학회지
65 세이상복압성요실금환자에게시행된 Canal transobturator tape 수술법 Table 4. Self assessment questionnaires IIQ and UDI Preoperative scores Postoperative scores p value Incontinence impact questionnaire (IIQ)-7 Urogenital distress inventory (UDI)-6 8.4±3.9 5.6±4.2.95±1.7.15±1.1 <.5 <.5 료법의발전에도불구하고하부요로계증상이있는환자들이병원을찾아가는행동양식에는큰변화가없는것으로보고되고있으므로, 의료진은환자의하부요로계증상여부를확인하고환자가적절한처치를받을수있도록해야한다 [1]. 고령환자의요실금은배뇨근과활동성, 배뇨장애, 내인성괄약근기능부전이합병되는경우가많고절박뇨가지속되거나새롭게발생하는경우요로폐쇄의빈도가높은것으로보고되고있다 [11]. 수술전평가에서자세한병력청취와이학적검사, 요역동학검사를통해수술이후의경과를예측하고동반된하부요로증상에대한약물요법, 방광훈련, 생체되먹임 (biofeedback) 요법과자기장치료, 골반저근육운동과같은추가적인치료계획을세울필요가있으며, 고령환자의경우절박성요실금이지속되거나, 치료에실패하거나, 하부요로폐쇄같은배뇨곤란증상이오래지속될수있음을환자에게설명해야한다 [11,12]. 고령환자에게흔히동반되는내인성괄약근기능부전이있는경우 TVT가 TOT보다효과가높다고알려져있다 [13]. 본연구에서는내인성괄약근기능부전이동반된 1명의환자모두에서수술후요자제 (continence) 가지속적으로잘유지되었다. 본연구에서관찰된고령환자들의수술관련합병증은수술당일혹은수술후 1일째에나타나는통증, 일시적혈압상승등과같은경미한증상들이었으며, 특별한처치없이호전되었다. 고령환자에서는요로계문제가아닌폐색전, 부정맥, 심부정맥혈전증또는마취후의섬망등이주요합병증 (nonurological complications) 이다 [12,14]. 한연구에서는심혈관계기저질환이없는경우 75세이상에서비뇨부인과수술합병증의발생빈도가낮게나타났으며, 또다른연구에서는고령이슬링수술의치료실패의원인은아니라고보고하였다 [15,16]. 1여년전에여성의복압성요실금치료로슬링수 술이제안된이후지난 25년간다양한수술법들이시도되었는데, 슬링수술은 retropubic suspension과 transvaginal suspension 및 antierior repair보다치료효과가좋았다 [17]. 슬링수술에서수술이환율 (surgical morbidity) 와회복시간을감소시키고내구성 (durability) 이좋고거치 (placement) 가쉬운방법들이지난수년간개발되어왔다. 복압성요실금에서방광경부과운동성을교정하지않고도 urethropelvic ligament를강화하는요도지지 (urethral support) 를통해성공적인요자제를유지할수있다는사실이발견 (integral theory) 된이후, 명확한기전이밝혀지지는않았지만 midurethral slings 수술은전세계적으로널리사용되는요실금의수술적치료법이되었다 [18]. 근래에는매우다양한장비와상업적인키트 (kit) 들이개발되어소개되고있다. 그러나일부키트는비용이매우높고, blind procedure가필요한경우가많다. 촉각유도 (tactile guidance) 를가능하게하여주요합병증 ( 방광천공, 장및주요혈관손상 ) 을감소시킬수있는방법으로 suburethral tunnel을만들고치골뒤공간으로접근하는방법이 Raz에의해고안되었다 [19]. 또한치골뒤공간을피하는방법으로개발된 TOT는치료효과가우수하고합병증발생률이낮아최근널리이용되고있다 [19,2]. TOT 시술시에는 TVT와같이정중요로접근법 (midurethral approach) 을시행할때전질벽의 midurethral level에서정중절개후에 periurethral fascia를박리한후손가락유도 (finger guide) 하에회음부찌름절개창 (perineal stab incision) 과질벽절개사이로바늘을통과시켜슬링을걸어주게된다. 이과정에서질벽절개선이확장되고, 요도조직 (urethral tissue) 을직접손상할가능성이높아지며, 폐쇄공막을정확하게촉지하기가실제적으로어렵고, 바늘이통과하는위치가대퇴주름에서 one finger breath만큼외측으로나가게된다. 이과정에서일어난방광천공, 요도손상등이이 Vol. 13, No. 2, 29 125
최경미 이세진 이정훈 최중섭 김계현 한종설 이교원 미보고된바있다 [2,21]. 본원비뇨부인과에서는 suburethral canal을이용한 DUPS 수술법과기존의 TOT 수술법을접목하여새롭게소개한 Canal TOT 수술법의 1년간의치료효과를분석하여보고한바있다 [6]. 전질벽의외측박리를통해 urethropelvic ligament가나타나면검지를이용하여외측박리를진행시켰을때여유있게엉덩궁둥뼈가지 (ischiopubic ramus) 의후연과폐쇄공막을촉지할수있으며골반근막힘줄활 (tendinous arch of pelvic fascia) 역시쉽게확인할수있다. tunneler needle을통과시킬때 ichiopubic ramus 외측을타고진행시키는단계에서부터바늘끝을촉지하고골반근막힘줄활과 ischiopubic ramus 후연사이로바늘끝을통과시켜폐쇄공의주요구조물의손상가능성을더욱줄일수있다. 또한대퇴주름내측에서바늘을통과시켜슬링을걸어주게되므로수술부위를감소시키는효과도있다. 고도의방광류가동반되어시행한방광류복원술을슬링수술과함께시행할경우에는배뇨후잔뇨량검사를수술후 3일째에시행한다. 통증으로인한배뇨곤란을호소하는경우가있으나추가적으로 24 48시간정도도뇨관을유치한후자연배뇨를확인할수있었다. 수술후혈종, 감염, 누공, 배뇨곤란, 하부요로폐쇄, 질벽미란, 요로미란과같은합병증은발생하지않았다. 일부에서는골반장기탈출증수술을같이시행한경우하부요로폐쇄의가능성이증가한다고보고하였으나 [22], 본연구에서는 6주이상지속되는배뇨곤란은발생하지않았다. 수술직후나타나는일과성요절박, 일시적인배뇨곤란증상은보존적치료로써호전되므로환자를안심시키는것이중요하다고생각된다. 고령환자에서 TOT 수술성공률이따로조사된연구는없으나평균나이가 68.1세인 TOT와질식수술 (vaginal surgery) 를함께받은그룹 (n=61) 의 12개월추적관찰에서수술성공률은 85.2% 였고수술후요저류는 11.5% 에서발생하였다 [23]. 또다른연구에서 75세이상환자에서슬링수술시행 1년후재발률이 1.5% 로나타났다 [22]. 본연구에서는수술후 6개월에치료율이 96.4% 였으며수술후 12개월추적관찰된 31명의환자들중에재발은발생하지않았다. 방광미란, 요도미란, 혹은질벽미란과같은합병증은없었고수술후일시적인배뇨곤란발생률이 5.5% 였다. 대상환자군의기준이다르고짧은추 적관찰기간, 사용된수술법들도다른연구들로통계적으로의미있는차이를확인할수는없으나치료효과나합병증발생률을볼때 Canal TOT 수술법은기존의슬링수술과비교할만한결과를나타내고있다. 고령환자에시행한 Canal TOT의경과는장기적인추적관찰이필요하지만현재까지나타난결과들은그치료효과가높고합병증발생률이낮다는것을볼수있다. 결론본연구는변형된 midurethral sling operation인 Canal TOT수술법이 65세이상고령환자에서심각한합병증없이높은치료효과를나타내므로복압성요실금의치료법으로서안전하고유용하게사용될수있다는것을보여준다. 그러나본연구는새로운수술법을시행받은일부환자들을대상으로단기간의경과만을관찰한것이므로, Canal TOT의효용성을확실히하기위해서는대단위환자를대상으로한장기적인연구가필요할것으로사료된다. References 1) Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation ofterminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 23;61:37-49 2) Anger JT, Saigal CS, Stothers L, Thom DH, Rodriguez LV, Litwin MS. The prevalence of urinary incontinence among community dwelling men: results from the National Health and Nutrition Examination survey. J Urol 26;176:213-8 3) Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:51-6 4) Long CY, Hsu CS, Wu MP, Liu CM, Wang TN, Tsai EM. Comparison of tension-free vaginal tape and transobturator tape procedure for the treatment of stress urinary incontinence. Curr Opin Obstet Gynecol 29;21:342-7 5) Rutman M, Itano N, Deng D, Raz S, Rodriguez LV. 126 대한배뇨장애요실금학회지
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