임신중발생한급성요관폐색에대한요관부목삽입술의유용성 The Usefulness of Ureteral Stenting for Acute Ureteral Obstruction in Pregnancy Sung Dae Kim, Luck Hee Sung, Choong Hee Noh From the Department of Urology, Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea Purpose: An acute ureteral obstruction during pregnancy presents both diagnostic and therapeutic challenges. When conservative therapy fails, temporary measures, such as ureteral stenting, are often chosen as a firstline intervention, which postpones definitive management until delivery. The usefulness of ureteral stenting was evaluated as an emerging strategy for the symptoms of an acute ureteral obstruction during pregnancy. Materials and Methods: Between 1996 and 2005, a retrospective analysis was performed on 53 pregnant patients with an acute ureteral obstruction. Eighteen of the patients were treated by ureteral stenting, as they failed to improve with conservative management. They were followed up until the removal of the ureteral stent. Results: Seventeen patients (95%) experienced significant pain relief within at least 2 days, but one patient (5%) did not. On ultrasound, 16 patients (88%) had resolution of hydronephrosis. Twelve patients (66%) continued to have problems with post-therapeutically irritative voiding symptoms, but 11 (61%) experienced relief of symptoms within 10 days. One patient (5%) had the ureteral stent removed due to the continuous complaint of irritative voiding symptoms. After delivery, all patients were taken intravenous pyelography (IVP). Fourteen patients showed normal findings, but 4 were diagnosed with a ureteral stone. Three patients were treated by extracorporeal shock wave lithotripsy (ESWL) for a stone in the upper and lower urinary tract. One patient, with a mid ureteral stone, was treated by ureteroscopic lithotripsy. Conclusions: Ureteral stents were usually placed without any major problems, and well tolerated, with only minor and short post-therapeutic discomfort. We concluded that ureteral stenting is a simple, safe and effective first-line therapeutic option in case of symptomatic and acute ureteral obstruction during pregnancy. (Korean J Urol 2006;47:1220-1224) Key Words: Pregnancy, Ureteral obstruction, Stents 대한비뇨기과학회지제 47 권제 11 호 2006 인제대학교상계백병원비뇨기과 김성대 성락희 노충희 접수일자 :2006년 6월 5일 채택일자 :2006년 7월 6일 교신저자 : 성락희상계백병원비뇨기과서울시노원구상계 7 동 761-1 }139-707 TEL: 02-950-1139 FAX: 02-939-6133 E-mail: uroman1@ yahoo. com 서론임신중에발생하는상부요관의확장은대부분생리학적인요인에의한것으로알려져있으며, 일반적으로동통이나신손상을유발하지않는다. 이러한상부요관의확장은임신중기이후약 90% 이상에서나타나며, 주로우측에서호발하는것으로알려져있다. 1,2 상부요관확장의원인으로는태반의위치, 모체의골반크기, 자궁내태아의체중및 확장된난소정맥이직접요관을압박함으로써발생하는해부학적요인, 프로제스테론, 에스트라디올등과같은호르몬작용및요관결석, 종괴등과같은내인적요인에의해서도발생하는것으로알려져있다. 1,3 그어떤원인에서든지급성으로요관폐색이발생하는경우에는심한동통, 혈뇨및패혈증을동반한신감염을일으킬수있고, 때로는신기능을저하시키며, 조기분만을조장할수있으므로적절한치료가필요하다. 저자들은증상을호소하는급성요관폐색을보이는 53명 1220
김성대외 : 임신중발생한급성요관폐색에대한요관부목삽입술의유용성 1221 의임산부중보존적치료에도호전되지않고증상이지속되는 18명에게요관부목삽입술을시행하였으며, 정기적으로추적관찰을시행하여임신중일차적치료로서요관부목삽입술의유용성에대해알아보고자하였다. 대상및방법 1996년 9월부터 2005년 12월까지급성요관폐색을보인임산부 53명중보존적치료에호전되지않는 18명을대상으로하였다. 모든환자에게자세한병력조사와요검사, 요배양검사, 신장초음파, 태아에대한평가를시행하였다. 신장초음파는신장의크기, 수신증의정도, 급성통증을유발하는원인을관찰하고자하였다. 치료로는보존적치료를우선시행하였으며, 적절하게측면와위를취하면서진통제및항생제를사용하였고, 복부초음파로수신증의정도를추적관찰하였다. 보존적치료가실패했다고판단한기준은발열등감염의문제가계속해결이안되거나, 신기능의저하가나타날때, 도플러신초음파상요관내요류가명확하게보이지않거나도저히참을수없는통증이계속될때로정의하였다. 4 보존적치료가실패하였다고판단한환자에서국소마취하에앙와위자세를취하고요관경 (Olympus R, Germany, 9.5Fr) 을삽입한후, 요관구를확인하고유도철선을이용하여요관부목 (polyurethane Double-J stent, Cook R, USA, 4.7Fr, 22-26cm) 을삽입하였다. 요관부목의선택은단순요로촬영에서요관의길이를측정한후이에맞는크기를선택하였다. 요관부목이정위치에있는지유무를초음파로확인하였으며, 수신증의정도및증상의유무를주기적으로추적관찰하였다. 분만후모든환자에서배설성신우조영술을시행하였고, 외래에서방광경하에요관부목을제거하였다. 결과내원환자의연령분포는 23세에서 38세까지였으며, 평균연령은 27세 (23-33) 였다. 14명이초산이었고, 3명이두번째, 1명이세번째임신이었다. 제태시기는초기가 2명이었고, 중기가 5명, 말기가 11명이었으며, 평균제태기간은 25주 (8-32) 였다. 과거력에서 3명의임산부가요로결석으로치료받은병력이있었다. 신체검사에서늑골척추각압통외에는특이소견이없었다. 12명이우측측복부통, 4명이좌측측복부통, 2명은양쪽모두통증이있었으나좌측보다는우측이심하다고호소하였다. 검사실소견에서 5명의환자에서농뇨가관찰되었고, 3명은요배양검사에서 E. coli가배양되어항생제치료를하였다. 세균뇨로항생제치료를 받은 3명은이후추적관찰한요검사및요배양검사에서특이소견이나타나지않았다. 복부초음파에서수신증의정도를살펴보면경도가 2명, 중등도가 11명, 중증도가 5명이었으나, 급성폐색의원인을뚜렷하게발견할수없었다. 수술시간은평균 22분 (16-35) 이었으며, 술중요관점막손상이나요관파열등의합병증은없었다. 술후초음파에서 18명중 16명 (88%) 에서수신증의정도가감소하는것을확인할수있었으며, 구체적으로중증도는한명도없었으며중등도가 2명, 경도가 3명, 수신증이없어진경우가 13명이었다 (Fig. 1). 이중에서 17명 (95%) 은통증이완화되었으나, 1명 (5%) 은지속되었다. 요관부목삽입술후 12명 (66%) 에서배뇨통, 급박뇨, 빈뇨등의방광자극증상및혈뇨가나타났으나, 11명 (61%) 은보존적요법으로 10일이내에증상이호전되었다. 보존적요법에도불구하고 1명에서증상이호전되지않아요관부목을제거하였으며, 제거후측복부통등의요관폐색으로인한증상이다시나타나지않아추적관찰하였다. 양측수신증을보인 2명은더심한통증을호소한우측에만요관부목을삽입하였다. 산모와태아의건강상태는술후산부인과의사에의해평가받았으며, 특이소견은없었다. 제태초기였던 2명의임산부는출산시기와차이가많이나서후기에요관부목을교체하였고, 나머지는시행하지않았다. 18명의임산부중 1명을제외한모든임산부들은제태기간 37주이후정상분만하였고, 1명은 34주에조기분만하였는데요관부목삽입술시행 6주가지난후조기양막파열로인한경우로요관부목삽입술과의관련성이적었다. 요관부목삽입술을시행한 18명모두가분만후배설성신우조영술을시행하였다. 배설성요로조영술에서 14명은정상으로판단되어요관부목을외래에서제거하였 No. patient 14 12 10 8 6 4 2 0 Follow-up ultrasonography with ureteral stenting during pregnancy Before After None Mild Moderate Severe Level of hydronephrosis Fig. 1. Ultrasonic follow-up on ureteral stenting during pregnancy (n=18).
1222 대한비뇨기과학회지 : 제 47 권제 11 호 2006 Table 1. Demographics and results in 18 women who underwent ureteral stenting during pregnancy Radiologic finding Final outcome Pt. Age Gestation Past Ureteral HD Parity Site Degree of Stone No. (year) (week) history complication after stenting Urologic Obstetric* HD confirmed 1 23 Primipara 12 Rt. Moderate - - Dysuria Decrease Stent removal postpartum 38/40 SVD 2 24 Primipara 8 Rt. Mild - - - Decrease Stent removal postpartum 38/40 SVD 3 24 Primipara 24 Lt. Moderate Upper ureter No interval ESWL and stent - Dysuria stone: 6mm change removal postpartum 41/40 SVD 4 26 Primipara 30 Bilat. Moderate - - Hematuria Decrease Stent removal postpartum 40/40 SVD 5 27 Primipara 18 Rt. Severe - Renal Stent removal Frequency Decrease stone postpartum 39/40 CS 6 30 Multipara 30 Rt. Moderate - - - Decrease Stent removal postpartum 41/40 SVD 7 26 Primipara 25 Rt. Severe Upper ureter Renal ESWL and stent Frequency Decrease stone: 4mm stone removal postpartum 38/40 SVD 8 30 Primipara 24 Rt. Moderate - - - Decrease Stent removal postpartum 38/40 CS 9 27 Primipara 26 Lt. Moderate Lower ureter Ureter ESWL and stent Hematuria Decrease stone: 4mm stone removal postpartum 40/40 SVD 10 31 Multipara 29 Lt. Moderate - - Dysuria Decrease Stent removal postpartum 37/40 SVD 11 30 Primipara 24 Rt. Moderate - - Dysuria Decrease Stent removal postpartum 47/40 CS 12 26 Primipara 27 Rt. Severe - - Frequency Decrease Stent removal postpartum 38/40 CS 13 25 Primipara 27 Rt. Moderate - - Dysuria No interval Stent removal at POD #1 change d/t dysuria 39/40 SVD 14 31 Multipara 30 Bilat. Moderate - - Dysuria Decrease Stent removal postpartum 38/40 SVD 15 28 Primipara 21 Rt. Moderate - - Dysuria Decrease Stent removal postpartum 41/40 CS 16 27 Primipara 32 Rt. Severe - - Hematuria Decrease Stent removal postpartum 42/40 CS 17 26 Primipara 28 Rt. Mild - - - Decrease Stent removal postpartum 34/40 CS 18 33 Multipara 31 Lt. Severe Mid ureter URS postpartum+stent 38/40 SVD - Dysuria Decrease stone: 5mm removal 3 day after URS *: numbers are weeks gestation on delivery, : numbers are weeks gestation when underwent ureteral stenting, HD: hydronephrosis, CS: cesarean section, SVD: spontaneous vaginal delivery, URS: ureteroscopic removal of stone, ESWL: extracorporeal shock wave lithotripsy, : premature rupture of membrane 6 weeks after ureteral stenting 고, 결석으로진단된 4명중 3명은체외충격파쇄석술을 1회시행하여결석이제거된것을단순요로촬영으로확인후요관부목을외래에서제거하였으며, 중부요관결석이있는 1명에서는요관경하배석술을시행하였고, 이후외래에서요관부목을제거하였다 (Table 1). 고찰임신중에발생하는상부요관의확장은정상적인현상으로임산부의약 90% 에서나타난다. 1,2 이러한요관의변화는해부학적으로는태반의위치, 자궁내의태아의체중, 모체의골반크기및확장된난소정맥이직접요관을압박함으로써발생하며, 평활근이완을일으키는프로제스테론, 에스트라디올등과같은호르몬작용, 요관결석, 종괴등과 같은내인적요인에의해서도발생하는것으로알려져있다. 신장초음파를이용하여최고신배길이 (maximum calyceal diameter) 를측정한단계적체계 (grading system) 에따르면, 임신중 90% 이상에서경도의요관확장이우측에서발생하고, 5,6 이는확장된자궁이우측으로편향되어있기때문이다. 임신중요로결석의발생빈도는 1,500명당약 1 명정도지만임신동안복부통증으로병원을방문하는가장빈번한원인중하나로알려져있으며, 산모및태아에게심각한위험을초래하는경우도있다. 심지어임신중요관폐색으로인해확장된신장이자발적으로파열된증례도보고되고있다. 7 저자들에게내원한환자로는발생빈도를알기는어렵지만 53명중 4명 (7.5%) 에서결석으로진단되었다. 또한과거력상결석으로진단받은 3명모두체외충격파쇄석술을받은경험이있어시술과급성요관폐색발생
김성대외 : 임신중발생한급성요관폐색에대한요관부목삽입술의유용성 1223 에어느정도관련성을찾을수있다. 임신중에결석형성에영향을미치는대사변화로는고요산뇨증, 고칼슘뇨증, 결석형성억제제의변화, 요정체, 탈수및요로감염등이있다. 임신중해부학적인요인및대사변화가있음에도불구하고결석이발생하는빈도는임신이아닌경우와차이가없고, 결석과관련된합병증의발생빈도또한차이가없는것으로알려져있다. 8 임신중결석으로인한통증은주로제태시기중기와말기에정상적인요관확장이요정체의원인이될때발생한다. 임신중해부학적및생리적변화로발생하는수신증에대한진단및치료는복통, 측복통, 혈뇨, 요로감염, 방광자극증상, 고열, 조기진통및전자간증등나타나는증상의정도에따라여러형태로다양하게시행되어왔다. 임신중복부통증에대한감별진단으로는신우신염, 결석등과같은비뇨기계질환, 외과적복통및임신과관련된산과질환을감별하여야한다. 진단및치료는임신하지않은경우와유사하고, 대부분의경우신장초음파를시행하여진단겸치료의정보를얻을수있다. 임신중통증의원인이결석일경우에는약 60% 이상에서보존적치료만으로도자연적으로결석이배출되는것으로알려져있다. 임신중에발생하는측복부동통, 혈뇨등의증상이보존적치료에반응하지않고계속되는경우에는신속한검사및치료를시행하여임신과연관된신감염, 신기능저하및패혈증등이발생하지않도록하여야한다. 특히다태임신, 양수과다임신, 단일신일경우에발생한요관폐색그리고양측요관폐색이신부전을초래한경우도보고되고있기때문에신속하게요관폐색을확인하는검사및치료가반드시필요하다. 9,10 검사로는혈액및요검사, 초음파검사, 배설성요로조영술, 복부골반전산화단층촬영및자기공명요로조영술 (magnetic resonance urography) 등을시행하여요관폐색의원인을확진한다. 11 그러나, 방사선검사를시행할경우에는태아가방사선에노출되어사망혹은기형및암발생의가능성이있으므로촬영하는필름수를제한하거나방사선차단복등을이용하여태아에게최소한의방사선에노출되도록세심한주의가필요하다. 12 치료로는자세변경및진통제, 항생제등의약물요법을이용한보존적치료를우선시행하게되는데이러한방법으로증상이호전되지않는경우 Hettenbach 등 13 은베타차단제를투여하면효과가있다고주장하였으나, 아직까지널리이용되지는않고있다. 양측요관폐색으로발생한신부전의경우는임신중태아에게나쁜영향을줄수있으므로조기유도분만, 투석, 요관부목삽입술, 경피적신루설치술등을빠른시간내시행하여야한다. 증상을일으키는급성요관폐색의치료는아직확실히정립 되어있지는않지만, 대부분에서는태아의제태기간과연관지어치료를시행하고있다. 태아가생존할수있을정도로충분히성숙했다고판단되는경우에는유도분만을선택할수있으며, 만약태아가충분히성숙하지못한경우에는일차적으로적절하게측면와위를취하면서약물요법을시행하게되는데, 증상이호전되지않을경우에는수술적치료를시행하게된다. 현재까지시행되고있는치료법으로는경피적신루설치술, 요관부목삽입술, 및요관경하배석술등이이용되고있다. 요관경하배석술은최근더작은요관경과연성요관경의개발과함께과거에주로사용하던요관점막손상이나요관천공의위험도가높은전기수압파쇄석기 (electrohydraulic) 외에기압파 (Lithoclast), 초음파 (ultrasonic) 및레이저쇄석기 (holmium:yag) 등 14 다양한체내쇄석기의개발및술기의발달, 임신시요관의정상적인확장등으로요관경하배석술의효능이더욱증가하여임신중요로결석으로인한급성요관폐색이있는경우에이용이증가되고있다. 그러나체내쇄석기가태아에게미치는영향에대하여아직정립된바가없고, 요관점막손상이나천공의가능성이있으며, 임신시급성요관패색의원인이결석인경우가 0.05-0.5% 로미미하기때문에일차적치료법으로시행하기에는무리가따른다. 경피적신루설치술은국소마취하에쉽게시행할수있고, 초음파를이용하므로임신중방사선투여를피하거나최소화할수있으며, 통증및폐색을즉시완화시키는장점이있으나, 초음파유도하에시행하므로중등도의수신증이있어야하고, 이물질에의한신루의막힘이빈번하여자주교환이필요하고, 신루를통하여세균의감염이발생할수있고, 일상생활을유지하며활동하기에불편하다는것이단점으로지적되고있다. 15 일부에서는경피적신루설치술을여전히선호하고있지만, 16 최근에는요관부목을이용하여치료하는방법이흔히사용되며여러문헌이발표되고있다. 17,18 최근요관부목삽입술이널리이용되고있는데, 안정하고, 간편하며, 국소마취하에가능하다. 요관부목삽입술로인한합병증으로빈뇨, 야간뇨, 혈뇨등의방광자극증상, 하복부통, 부목주위가피형성등이있을수있으며, 19,20 방광요관역류로인해상행성신우신염이발생할수있다. 그러나, 대부분의합병증은보존적요법으로해결이가능하고, 임산부의경우요관부목을삽입하지않을경우, 통증으로인한조절이쉽지않고, 입원을반복할가능성이높기때문에요관부목삽입술을시행하여급성요관폐색을제거해주는것이옳다. 저자들은보존적요법으로치료되지않는 18명의환자에서요관부목삽입술을시행하였는데, 12명이방광자
1224 대한비뇨기과학회지 : 제 47 권제 11 호 2006 극증상및혈뇨를호소하였으나, 한명을제외하고는보존적요법으로해결되었고, 부목주위가피형성또한없었다. 임신중보존적요법으로해결되지않는수신증및측복부통을호소하는환자에서일차적치료로서요관부목삽입술은간단하고, 안전하며, 일상생활에불편함이없을뿐만아니라효과적이다. 결 보존적치료로증상이호전되지않는급성요관폐색을보인임산부에서요관부목삽입술은국소마취하에가능하고, 매우간편하면서도시행중특별한부작용이발생하지않았으며, 시행후증상이단기간내에호전되었다. 요관부목삽입술후중대한합병증은발생하지않았고, 빈뇨, 급박뇨, 배뇨통등과같은방광자극증상및혈뇨는단기간내에보존적요법으로간단히해결되었다. 이에저자들은임신중발생한급성요관폐색에대한치료법으로보존적치료에도반응하지않고증상이지속되는경우, 일차적치료로서요관부목삽입술은시술이간단하면서도안전하고증상을완화시키는데에효과적인방법이라고판단된다. 론 REFERENCES 1. Gorton E, Whitfield HN. Renal calculi in pregnancy. Br J Urol 1997;80(Suppl 1):4-9 2. Swanson SK, Heilman RL, Eversman WG. Urinary tract stone in pregnancy. Surg Clin North Am 1995;75:123-42 3. Clayton JD, Roberts JA. The effect of progesterone on ureteral physiology in a primate model. J Urol 1972;107:945-8 4. Fainaru O, Almog B, Gamzu R, Lessing JB, Kupferminc M. The management of symptomatic hydronephrosis in pregnancy. BJOG 2002;109:1385-7 5. Schulman A, Herlinger H. Urinary tract dilation in pregnancy. Br J Radiol 1975;48:638-45 6. Cietak KA, Newton JR. Serial qualitative maternal nephrosonography in pregnancy. Br J Radiol 1985;58:399-404 7. Hwang SS, Park YH, Lee CB, Jung YJ. Spontaneous rupture of hydronephrotic kidney during pregnacy: value of serial sonography. J Clin Ultrasound 2000;28:358-60 8.Jarrard DJ, Gerber GS, Lyon ES. Management of acute ureteral obstruction in pregnancy utilizing ultrasound-guided placement of ureteral stents. J Urol 1993;42:263-8 9. Webb JA. Ultrasonography and Doppler studies in the diagnosis of renal obstruction. BJU Int 2000;86(Suppl 1):25-32 10. Shokeir AA, Mahran MR, Abdulmaaboud M. Renal colic in pregnant women: role of renal resistive index. Urology 2000; 55:344-7 11. Birchard KR, Brown MA, Hyslop WB, Filat Z, Semelka RC. MRI of acute abdominal and pelvic pain in pregnant patients. AJR Am J Roentgenol 2005;184:452-8 12. Tschada R, Mickisch G, Rassweiler J, Knebel L, Alken P. Success and failure with double J ureteral stent. Analysis of 107 cases. J Urol (Paris) 1991;97:93-7 13. Hettenbach A, Tschada R, Hiltmann WD, Zimmermann T. The effect of beta-stimulation and beta-1-blockade on the motility of the upper urinary tract. Z Geburtshilfe Perinatol 1988;192: 273-7 14. Akpinar H, Tufek I, Alici B, Kural AR. Ureteroscopic and holmium laser lithotripsy in pregnancy: stent must be used postoperatively. J Endourol 2006;20:107-10 15. Khoo L, Anson K, Patel U. Success and shot-term complication rates of percutaneous nephrostomy during pregnancy. J Vasc Inter Radiol 2004;15:1469-73 16. Kavoussi LR, Albala DM, Basler JW, Apte S, Clayman RV. Percutaneous management of urolithiasis during pregnacy. J Urol 1992;148:1069-71 17. John H, Vondruska K, Sulser T, Lauper U, Huch A, Hauri D. Ureteral stent placement in hydronephrosis during pregnancy. Urologe A 1999;38:486-9 18. Knudsen BE, Beiko DT, Denstedt JD. Stenting after ureteroscopy: pros and cons. Urol Clin North Am 2004;31:173-80 19. Spirnak JP, Resnick MI. Stone formation as a complication of indwelling ureteral stents: a report of 5 cases. J Urol 1985; 134:349-51 20. Duvdevani M, Chew BH, Denstedt JD. Minimizing symptoms in patients with ureteric stents. Curr Opin Urol 2006;16:77-82