사정관낭종및폐색이동반된혈정액증환자에서경요도사정관소작술 Effectiveness of Transurethral Coagulation and Incision of Ejaculatory Duct for Hematospermia Caused by Ejaculatory Duct Cyst and Obstruction Korean Journal of Urology Vol. 50 No. : 7-77, March 009 DOI: 10.111/kju.009.50..7 Pil Moon Kang, Jae Il Chung From the Department of Urology, Inje University, College of Medicine, Busan, Korea Purpose: To evaluate the usefulness and effectiveness of transurethral coagulation and incision of the ejaculatory duct for hematospermia caused by ejaculatory duct cyst and obstruction. Materials and Methods: Twenty-six patients with hematospermia were enrolled. Ejaculatory duct cyst or obstruction was diagnosed by transrectal ultrasound or MRI, revealing seminal vesicle hypertrophy and cystic dilated ejaculatory ducts. One patient had hematospermia associated with infertility. The mean age of the patients and their duration of symptoms were.7 years (range, 5-7 years) and 1 months (range, 1-0 months), respectively. All patients underwent transurethral management for treatment of their ejaculatory duct obstruction in the form of incision and coagulation of the ejaculatory duct. We used a 9.5 Fr rigid ureteroscope (Stortz R, Germany) and a Bugbee electrode. Patients were followed for more than months after the procedure. Results: All patients reported improvement of hematospermia and disappearance of midline cysts, except for one patient. The one case, ureteroscope failed to pass through verumontanum. A ejaculatory duct cyst was found in 18 cases. Calculi were present in the seminal vesicle and ejaculatory ducts in 7 patients and were removed with endoscopic instruments. One infertile patient regained reproductive ability after the procedure. Postoperative complications, such as epididymitis, orchitis, or retrograde ejaculation were not observed. Conclusions: Transurethral incision and coagulation was a safe and effective treatment option for hematospermia caused by ejaculatory duct obstruction and is considered to be a successful treatment option for infertility secondary to ejaculatory duct obstruction. (Korean J Urol 009;50: 7-77) Key Words: Hemospermia, Ejaculatory ducts, Endoscopy, Infertility 인제대학교의과대학비뇨기과학교실 강필문ㆍ정재일 Received:January 9, 009 Accepted:February, 009 Correspondence to:jae Il Chung Department of Urology, Inje University Paik Hospital, -15, Gaegum-dong, Busanjin-gu, Busan 1-75, Korea TEL: 051-890-8 FAX: 051-89-9887 E-mail: prosdoc@hanmail.net This work was supported by the 005 Inje University research grant. C The Korean Urological Association, 009 서론혈정액증은고환, 부고환, 정관, 정낭, 전립선등에이상이있는경우에발생할수있지만주로정낭, 사정관, 전립선의병변이대부분이다. 특별한원인이밝혀지지않은경우가많으며, 감염, 양성질환, 악성종양과손상이주된원인 으로알려져있다. 1- 하지만최근에경직장초음파검사가보편화되고자기공명영상술, 내시경등의발달로정낭, 사정관, 전립선의해부학적인병변부위를관찰할수있게되면서정액배출의폐쇄가혈정액증의중요한원인중하나인것으로보고되고있다.,5 이에저자들은혈정액증을호소하는환자중에서경직장초음파검사와자기공명영상에서정낭의확장및낭종, 사 7
Pil Moon Kang and Jae Il Chung:Transurethral-Coagulation and Incision in Hematospermia 7 정관낭종, 정낭또는사정관결석등의사정관의폐색및해부학적병변이보이는환자에대해요관경을이용한경요도사정관지혈술및절개술을시행하여효과및안정성에대해평가하였다. 대상및방법 005년 월부터 008년 1월까지혈정액증을주소로내원한환자는 91명이었다. 자세한병력청취와직장수지검사등의신체검사를시행하였으며일반요검사, 정액검사및 0세이상의환자에서는혈청전립선특이항원검사를시행하였다. 회음부, 치골상부불편감및사정시동통등의만성전립선염및골반통증후군이의심되는환자에서는전립선마사지를통한전립선액검사를추가로시행하였다. 요검사, 전립선액검사또는정액검사에서염증세포가관찰될경우, -8주간의항생제요법을처방하고경과를관찰하였으며전립선과정낭의병변을관찰하기위하여경직장초음파검사및전립선자기공명영상술을시행하였다. 보존적치료에도불구하고혈정액증이지속되며경직장초음파검사와자기공명영상술에서정낭의확장및낭종, 사정관낭 Fig. 1. A 9.5 Fr rigid ureteroscope was inserted into the ejaculatory duct cyst via the utricular orifice at the verumontanum. (A) The prostate utricular orifice at the verumontanum. (B) The utricular lumen. (C) The ejaculatory duct cyst; stones and hemorrhage were identified and bilateral ejaculatory duct orifices were not identified. (D, E) Stones are removed by ureteroscopic foreign body forceps. (F) Right ejaculatory duct opening. (G) Ejaculatory duct cyst wall was electrocauterized and closed ejaculatory opening was opened (dark circle). (H) Left ejaculatory duct opening.
7 Korean Journal of Urology vol. 50, 7-77, March 009 종, 정낭또는사정관결석등의해부학적병변이보이는환자 명을대상으로경요도정낭내시경술과경요도사정관지혈술및절개술을시행하였다. 1례에서혈정액증과불임증이동반되었으며 례에서사정시통증및회음부불편감을호소하였다. 요관경을이용한경요도정낭내시경술및사정관지혈술은전신또는하반신마취하에방광요도내시경을이용하여방광과전립선요도를관찰한후정구의위치를확인하여정구내로 0.05 inch 유도철선을삽입한후 9.5 Fr 경성요관경 (Stortz R, Germany) 을이용해사정관및낭종내로진입하였으며, 유도철선의진입이힘들경우에는 5 Fr 요관카테터를이용하여정구를확장시킨후진입하였다. 낭종내부구조, 결석유무및사정관입구를확인후 Bugbee electrode를이용한낭종내부점막지혈술및낭종내에서양측에존재하는사정관입구를통해정낭까지진입하였으며사정관입 구가확인되지않을경우에는추정되는부위에 Bugbee electrode를이용한절개를통하여정낭까지진입하였으며사정관입구가좁아져있는경우에는확장술을시행하였다. 저류된정액, 혈액등의침전물이있는경우는생리식염수로세척을통해침전물의흡입제거및시야확보를하였다. 낭종내부의점막은충혈되어있었고응고된혈액을관찰할수있었으며이에대해소작술을시행하였다. 낭종이나정낭내에결석이있는경우는요관내시경기구를이용하여제거하였다 (Fig. 1). 술후유치한도뇨관은술후 1일째제거후퇴원하였다. 추적관찰은수술후 개월째육안적혈정액증의지속여부및경직장초음파검사를통한술전에발견된해부학적병변정낭및사정관의낭종및결석소실여부를확인하였으며술후부고환염이나역행성사정등의합병증발생에대해서조사하였다. Table 1. Clinical features and result of transurethral coagulation and incision for hematospermia No. 1 5 7 8 9 10 11 1 1 1 15 1 17 18 19 0 1 5 Age (years) 57 9 50 5 5 55 7 59 5 5 5 0 5 8 9 7 7 5 5 9 Hematospermia duration (months) 8 1 0 9 1 10 1 1 0 Midline cyst Calculi Seminal vesicle hypertrophy Concomitant symptoms Infertility Pain on ejaculation Pain on ejaculation Follow-up (months) Mean 5.8 1..8 8 15 1 10 5 8 Post operative persistant hematospermia Post operative persistant concomitant symptoms
Pil Moon Kang and Jae Il Chung:Transurethral-Coagulation and Incision in Hematospermia 75 결과요관경을이용한경요도사정관지혈술및절개술을시행받은환자는총 명이었으며평균나이는 5.8세 (5-7) 였다. 평균병력기간은 1.개월 (1-0) 이었으며, 모든환자에서경직장초음파검사와자기공명영상술에서정낭의확장및낭종, 사정관낭종, 정낭또는사정관결석등의해부학적이상소견을동반하고있었다. 18례에서사정관낭종을확인할수있었으며, 평균낭종크기는 0.8 cm (0.5-. cm), 정낭의확장은 1례, 결석은 7례에서확인할수있었다 (Table 1). 정구를통한요관경삽입이힘들어시술을하지못한 1례를제외한모든환자에서성공적으로시술을시행하였으며평균수술시간은 5분이었다. 낭종이확인된모든환자에서낭종내점막을전기소작술을시행하였다. 요관경삽입이가능했던모든환자에서사정관입구의협착또는폐색이동반된경우 Bugbee electrode를이용하여사정관절개술및확장술을시행하였다. 사정관낭종및정낭내에결석이 발견된경우에는내시경기구를이용하여제거하였다. 모든환자들은술후 1일째퇴원하였다. 정구를통한요관경삽입이힘들었던 1례를제외한모든환자에서혈정액증이소실되었으며, 추적경직장초음파검사에서도혈정액증이지속된 1례를제외하고는모든환자에서낭종소실이관찰되었다 (Fig. ). 혈정액증과함께불임증동반한 1례에서는시술전정액검사에서사정량감소및무정자 ( 정액량 <0.1 ml, 정자수 0 M/ml, 운동성 0%, 정상모양 0%) 소견이동반되었으나시술후정액검사에서정상사정량및정자수 ( 정액량 ml, 정자수 : 55 M/ml, 운동성 0%, 정상모양 70%) 로현저한정액소견개선을확인하였으며임신도성공하였다. 만성적으로사정시통증및회음부불편감을호소하던 명의환자에서도증상호전을나타냈다. 술후부고환염이나역행성사정등의합병증은관찰되지않았다. 고찰정액에혈액이섞여나오는혈정액증은일반적으로전립 Fig.. Preoperative (A, B) and postoperative (C, D) transrectal ultrasonographic (TRUS) findings. A round midline cyst (arrow) was disappeared after months of operation. A and C; axial scan, B and D; sagittal scan.
7 Korean Journal of Urology vol. 50, 7-77, March 009 선또는정낭의비특이적인염증으로인한것으로생각되며대부분의경우자연소실되기때문에다른증상이동반되지않을경우보존적인치료로경과를지켜보는치료법만으로도충분한것으로생각해왔다. 하지만대증적인치료에도불구하고혈정액증이지속된다든지재발하는경우는임상에서흔하게볼수있다. 현재까지유병률이나정확한원인에대해서는잘알려져있지않으나, 장기간의금욕생활을한후에빈번하게발생한다는보고가있으며특히부인이임신중인남성에게비교적유병률이높은것으로보고된다. 혈정액증의원인으로과거에는남성호르몬의영향으로정낭점막이비후되어발생한다고믿고여성호르몬을치료제로사용하기도하였으나, 현재는특별한원인이밝혀지지않는경우, 특발성이약 % 를차지하며, 전립선염, 부고환염, 정낭염과같은감염및양성질환이 9%, 이외악성종양과손상이 % 를차지하는것으로알려져있다. 1- 하지만특발성이라고생각되었던많은원인들중에경직장초음파검사, 자기공명영상술, 내시경등의영상기술의발달및보편화로정낭, 전립선, 정관팽대부등의해부학적인병변부위를확인할수있게됨으로써정액배출의폐쇄가혈정액증의중요한원인중하나인것으로밝혀졌다. 7-10 저자의경요도정낭내시경술결과에서도사정관입구의협착및폐쇄를확인할수있었으며사정관입구의확장및개통을통해서증상이사라진것으로보았을때이들의근거를뒷받침해준다. 혈정액증의진단을위해서는혈정액증의기간과재발성그리고혈뇨동반여부등을포함한충분한병력청취를해야하며혈액응고장애질환이나항응고약물복용등의동반질환유무도확인하여야한다. 하부요로증상, 사정통, 고환및회음부불쾌감, 불임등이동반된증상이있을경우비뇨기과적인진단과정이필요하다. 비뇨생식기감염이흔히동반되므로요검사, 요배양검사, 요결핵배양검사, 전립선액검사가도움이될수있으며 0세이상의경우에는드물지만전립선암등악성질환과의연관성에대해서도직장수지검사, 전립선특이항원수치 (prostate-specific antigen; PSA), 요세포검사도시행해볼수있다. 경직장초음파검사는혈정액증환자에서원인병변을밝히는데간편하고정확하여 1차적인선별검사로이용되고있으며, 혈정액증을보인환자들의경직장초음파검사에서이상소견으로는주로정낭의확장, 낭종, 사정관결석, 정낭결석, 뭘러관낭종등을관찰할수있다고보고하고있으며이는사정관폐색으로인한 차적인변화로생각한다. 11 경직장초음파검사에서정확한원인을찾기가어려운경우에추가적으로자기공명영상술을시행하여더욱상세한해부학적정보를얻을수있다. 혈정액증의치료는원인에따라다르지만대부분의경우는경미하고자연소실되기때문에 0세이하의젊은연령층에서혈뇨나다른동반된증상이없는경우는환자를우선안심시키고보존적인요법으로도충분하지만, 검사에서감염이원인으로생각되는경우에는염증에대한치료가우선되어야한다. 증상을일으키는전립선, 정낭, 사정관, 발생학적잔여구조물에생긴낭종들은전산화단층촬영술이나초음파를이용한낭종흡인술, 개복후낭종절제술등의방법이사용되어왔으나일시적이고재발가능성이높고, 침습적이라는문제를가지고있었다. 1-1 1980년대이후에는경요도정낭내시경이혈정액증의진단과치료에시도되고있은후현재까지우수한수술성적이보고되고있다. 15-17 Byon 등 은혈정액증의환자에서경소낭정낭내시경술을시행하여사정관협착이나폐색이있는경우사정관확장및절개술을시행한 7례중추적관찰이안된 1례를제외한 례에서술후에혈정액증이육안에서소실되었음을보고하였으며, Cha 등 5 의연구에서도재발성혈정액증으로경직장초음파 (transrectal ultrasonography; TRUS) 나자기공명영상술 (magnetic resonance imaging; MRI) 에서해부학적병변이있어경요도정낭내시경술을시행받은 1명의환자중 1개월이상추적관찰이가능하였던 11명의환자들에서육안적혈정액증이소실되어재발하지않았다고보고하였다. 본연구에서도사정관폐색이동반된혈정액증환자 명에서경요도사정관지혈술및절개술을시행하였으며요관경진입에실패했던 1례를제외하고는성공적으로시술을시행하였으며술후평균 개월에추적관찰시혈정액증은소실되었다. 만성적인사정시통증및회음부불편감을호소하던 명의환자에서는사정관폐색을해결한후에는증상이호전되었으며, 혈정액증과함께불임증동반한 1례에서는시술후임신에성공하였는데, Fuse 등 18 은정액검사에서무정자증또는정액감소증이있는남성에서신체검사, 호르몬검사에서특이소견은없으나경직장초음파에서사정관폐색이있는 10명을대상으로사정관절개술을시행하여 명 (0%) 의환자에서임신을하였으며 7명 (70%) 의환자에서는정자수및운동성의개선을보고하였다. Philip 등 19 은 세의무정자증을호소하는남성에서사정관낭종내결석을제거후정액검사에서정상적인정액량, 정자수및운동성획득을보고하였다. 이처럼사정관폐색이불임의원인이될수있으며불임을호소하는남성에서경직장전립선초음파또는자기공명영상에서사정관폐색소견이있을경우이시술을통해성공적으로해결할수있을것으로생각한다.
Pil Moon Kang and Jae Il Chung:Transurethral-Coagulation and Incision in Hematospermia 77 결 경요도내시경적사정관소작술및절개술을시행받은 명의환자중 1례에서는육안적혈정액증이지속되었으나이는정구를통한요관경삽입이힘들어실패하였던환자로, 이는사정관개통의실패로지속되는것으로생각한다. 사정관낭종및폐색이동반된혈정액증환자에게있어서경요도정낭내시경술및사정관소작술및절개술은기존의내시경을이용하여간단한술기로도시행할수있는장점이있으며, 높은성공률을보이는효과적이면서도합병증이적은안전한치료방법으로생각한다. 또한사정관폐색에의한 1차혹은 차불임증환자에서도이시술을통해성공적으로해결할수있으리라기대한다. 론 REFERENCES 1. Leary FJ, Aguilo JJ. Clinical significance of hematospermia. Mayo Clin Proc 197;9:815-7. Papp G, Molnar J. Causes and differential diagnosis of hematospermia. Andrologia 1981;1:7-8. Jones DJ. Haemospermia: a prospective study. Br J Urol 1991;7:88-90. Byon SK, Rha KH, Yang SC. Transutricular seminal- vesiculoscopy in the management of hematospermia. Korean J Urol 001;:9-5. Cha SH, Hong SH, Seo SI, Kim JC, Hwang TK. Effectiveness of endoscopic management in recurrent hematospermia. Korean J Urol 005;:88-9. Gerber GS, Brennder CB. Evaluation of the urologic patient: history, physical examination and urinalysis. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia: Saunders; 007;87 7. Mulhall JP, Albertsen PC. Hemospermia: diagnosis and management. Urology 1995;:-7 8. Munkel witz R, Krasnokutsky S, Lie J, Shah SM, Bayshtok J, Khan SA. Current perspectives on hematospermia: a review. J Androl 1997;18:-1 9. Furuya S, Ogura H, Saitoh N, Tsukamoto T, Kumamoto Y, Tanaka Y. Hematospermia: an investigation of the bleeding site and underlying lesions. Int J Urol 1999;:59-7 10. Papp GK, Kopa Z, Szabo F, Erdei E. Aetiology of haemospermia. Andrologia 00;5:17-0 11. Kim JY, Park SS. The findings of transrectal ultrasonography in evaluation of organic hemospermia. Korean J Urol 199; :811-1. Fuse H, Sumiya H, Ishii H, Shimazaki J. Treatment of hemospermia caused by dilated seminal vesicles by direct drug injection guided by ultrasonography. J Urol 1988;10:991-1. Abe M, Watanabe H, Kojima M, Saitoh M, Ohe H. Puncture of the seminal vesicles guided by transrectal real-time linear scanner. J Clin Ultrasound 1989;17:17-8 1. Williams RD, Sandlow JI. Surgery of the seminal vesicles. In: Walsh PC, Retik AB, Vaugh ED, Wein AJ, editors. Campbell's urology. 7th ed. Philadelphia: Saunders; 1998;08-1 15. Yang SC, Rha KH, Byon SK, Kim JH. Transutricular seminal vesiculoscopy. J Endourol 00;1:-5 1. Fuse H, Nishio R, Murakami K, Okumura A. Transurethral incision for hematospermia caused by ejaculatory duct obstruction. Arch Androl 00;9:-8 17. Li L, Jiang C, Song C, Zhou Z, Song B, Li W. Transurethral endoscopy technique with a ureteroscope for diagnosis and mangement of seminal tracts disorders: a new approach. J Endourol 008;:719-18. Fuse H, Mizuno I, Iwasaki M, Akashi T. Transurethral treatment of ejaculatory duct obstruction in infertile men. Arch Androl 00;9:9-1 19. Philip J, Manikandan R, Lamb GH, Desmond AD. Ejaculatoryduct calculus causing secondary obstruction and infertility. Fertil Steril 007;88:70