계명의대학술지제 35 권 2 호 Keimyung Med J Vol. 35, No. 2, December, 2016 140 거대양성전립선비대증 1 례 변혜진 신택준 정원호 하지용 박철희 김천일 계명대학교의과대학비뇨기과학교실 Huge enign Prostatic Hyperplasia Hye Jin yun, M.D., Teak Jun Shin, M.D., Won Ho Jung, M.D., Ji Yong Ha, M.D., Choal Hee Park, M.D., Chun Il Kim, M.D. Department of Urology, Keimyung University School of Medicine, Daegu, Korea Received: September 22, 2016 Revised: November 15, 2016 ccepted: November 21, 2016 Corresponding uthor: Ji Yong Ha, M.D., Department of Urology, Keimyung University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea Tel: +82-53-250-7047 E-mail: uroha@dsmc.or.kr The authors report no conflict of interest in this work. enign prostatic hyperplasia (PH) is one of the most common diseases in older men and it may be accompanied with significant problems in the quality of life. Histological changes of PH is starting at the age of 35, and there is induced in 60% of 60-year-old men, 80% of 80-year-old men, in 50% of the patient group may lead to lower urinary tract symptoms (LUTS). 74-year-old man with huge PH visited outpatient clinic with severe LUTS of an year duration. He was diagnosed with PH 11 years ago and underwent transurethral resection of prostate twice. However, the prostate grew up to remarkable size again, which lead to the bladder outlet obstruction (OO) and renal failure. There is no report for huge PH (above 300 g) in Korea, we report a case with huge prostate size that is measured 330 g and treated with suprapubic open prostatectomy. Keywords: enign prostatic hyperplasia, Lower urinary tract symptoms 서론 Copyright Keimyung University School of Medicine 2016 양성전립선비대증은노인에서가장흔한질병중하나이며삶의질과연관되어그중요성이부각되고있다 [1]. 전립선비대증은하부요로증상을일으켜요저류, 요로감염및신부전등의합병증을일으키는진행성질환으로노인인구가증가되고질병에대한관심이높아져새로이진단되고있는환자는점차증가하고있다. 전립선비대증의치료는크게대기요법,
거대양성전립선비대증 1 례 141 약물치료및수술로나뉜다. 최근약물치료의발전으로수술은점차감소되는추세이고기존의술식외에도다양한최소침습적치료법이개발되어그영역을확대해가고있다 [2,3]. 약물치료및최소침습적치료법 [3,4] 의발전에도전립선비대증에대한가장효과적인치료방법은여전히경요도전립선절제술과개복전립선절제술이다. 일반적으로전립선용적이 100 g 이상인경우에개복전립선절제술이권장되고있고유럽비뇨기과학회 (European Urological ssociation) 와미국비뇨기과학회 (merican Urological ssociation) 의지침에서는경요도전립선절제술이가능한전립선의최대용적을 80~100 g으로보고하였다 [1,5]. 나이가증가함에따라전립선은현저한크기로커질수있으며, 서구에서는거대전립선비대증에대한여러사례들이문헌에보고되어있다 [6,7]. 하지만, 국내에서는 300 g 이상의거대전립선비대증에대한보고가없고, 아주드문증례로, 330 g의거대전립선을치골상부개복전립선절제술로치료한 1례를문헌고찰과함께보고하고자한다. 증례 74세남자가 1년전부터심해진배뇨곤란을주소로내원하였다. 11년전개인의원에서전립선비대증을진단을받았고약물치료와경요도전립선절제술을 2차례시행받았다. 지속적인약물치료에도급성요저류가반복되었고, 양측하지부종과수신증및신후성신부전소견을보였다. 고혈압, 당뇨, 심부전, 신경질환과같은다른동반질환은없었다. 직장손가락검사 (digital rectal examination) 결과전립선비대가관찰되었고, 결절이만져지는것은없었다. 혈청 PS는 15.77 ng/ml였다. 혈액검사상혈액요소질소 (UN) 수치가 81 mg/dl, 크레아티닌 (creatinine) 수치가 4.99 mg/dl였다. 소변검사에서농뇨가관찰되었고, 소변균배양검사상녹농균이검출되었다. 컴퓨터단층촬영에서양측고등급의수신증과팽창된요관이관찰되었고, 전립선의크기는 300 g 이상으로추정되었다 (Fig. 1). 급성요저류및동반된요로감염을치료하기위해도뇨관삽입술및초음파유도하양측경피적신장루 삽입술 (percutaneous nephrostomy, PCN) 을시행하였고, 수액공급및항생제치료를우선적으로시행하였다. 방광내시경검사를통해전립선비대로인한요도및방광경부의내시경적폐색소견이관찰되었고, 양측요관구의위치는거대해진전립선때문에확인할수없었다 (Fig. 2). 따라서근본치료는방광경부와요관구에대한시야확보가유리한치골상부개복전립선절제술을계획하였다. 복부반월형횡절개 (Pfannenstiel) 로개복하였고, 방광목상부로돌출된거대한전립선과이와바로인접한양측요관구가확인되었다. 다량의출혈로수술중농축적혈구 11 pints를수혈하였고주변손상없이전립선은완전히제거되었다. 출혈부위지혈을위해 24 Fr 50 ml 도뇨관을경요도로삽입하고부풀린도관을방광경부까지견인되도록하였다. 안전장치로 20 Fr 5 ml 방광루도뇨관을치골상부에하나더유치하였다. 제거된전립선의크기는 16 9.5 8.5 cm이었고, 무게는 330 g 이었다 (Fig. 3). 수술후 6일째선행성신우조영술 (antegrade pyelography, GP) 을시행후양쪽신장루를제거하였다 (Fig. 4). 7일째경요도도뇨관을제거하였고 (Fig. 5), 술후 14일째전신상태호전되어퇴원하였다. 4개월째시행한컴퓨터단층촬영및 MG3 신스캔상양측수신증은호전된소견을보였고방사선약물의배설이원활하였다 (Fig. 6). 5개월째요속검사결과최대요속 (Qmax), 배뇨량 (voiding volume), 배뇨후잔뇨량은각각 17.3 ml/sec, 285 ml, 0 ml/sec이었다. 9개월째혈액검사상혈액요소질소수치가 21 mg/dl, 크레아티닌수치가 2.02 mg/dl였다. 고찰전립선의조직학적변화는 35세부터시작되고요도를압박하게되면서방광출구폐색을초래하고배뇨곤란을유발하는질환이양성전립선비대증이다 [8]. 60대남자의 60%, 80대남자의 80% 에서전립선비대증이발생하게되는데, 이중 50% 의환자군에서전립선비대증으로인한여러가지하부요로증상을유발하는것으로알려져있다 [9]. 과거에는동양인의전립선비대증
142 계명의대학술지제 35 권 2 호 2016 C D Fig. 1. bdominal computerized tomography scan show a large pelvic mass representing the prostate and Foley catheter mal-position at prostatic urethra with urinary obstruction (hydronephrosis) at transverse (&) and coronary (C&D) planes. 발생률이서양인에비해낮다고생각되었으나최근에는동서양간의발생률에큰차이는없는것으로밝혀졌다 [10]. 우리나라에서도식생활의서구화, 노령인구의증가에따라전립선비대증환자의수가증가하는추세이다 [11]. 전립선비대증관련하부요로증상은다양하게나타나는데이로인해일상적인생활을방해하고수면의질을떨어지게만들고 [12], 심리적우울감, 불안감을 초래할수있어노년의삶의질을떨어뜨리며 [13] 합병증으로인해드물게는생명을위협할수도있다. 전립선비대증의치료는대기요법, 약물요법, 수술요법이있다. 증상이경미하거나전립선의크기가크지않은경우에는약물요법만으로도좋은효과를볼수있다 [1,14,15]. 하지만본증례에서처럼약물치료에도불구하고증상이호전되지않거나일상생활에지장을주는심한경우, 불응성혹은재발성요저류, 전립선비대증으로
143 거대 양성 전립선비대증 1례 Fig. 2. Urethrocystoscopy show complete kissing sign (). oth ureteral orifices were not identified due to the protruded huge prostate (). Fig. 3. Macroscopic views of the giant benign prostatic hyperplasia weighed as 330 gm. 인한 신기능 저하, 지속되는 혈뇨, 방광결석으로 인한 이차적인 폐색, 반복적인 요로감염이 발생하거나 약물치료를 원하지 않고 적극적인 치료를 원하는 경우 수술치료의 적응증에 해당한다[16]. 특히 전립선 크기가 30~80 g인 경우에는 내시경을 이용한 경요도전립선절제술이 표준치료법이며 [17], 개복전립선절제술은 절개가 필요하고 회복기간이 길고 출혈의 위험이 있지만 전립선용적이 매우 크거나(100 g 이상) 동반된 방광 내 병변을 가진 환자에서는 완 치 적 인 수술방법으로 알려져 있다[18]. Varkarakis 등[19]은 232례의 개복전립선절제술의 추적관찰을 통해 의미 있는 증상개선과 매우 낮은 재치료율을 보고하였다.
144 계명의대학술지 제35권 2호 2016 C Fig. 4. ntegrade pyelograms: () Lt. side shows well contrast passage to bladder, () Rt. side shows complete obstruction, (C) ntegrade ureteral stent insertion. Fig. 5. Postoperative cystogram demonstrates contracted bladder volume. Fig. 6. bdominal computerized tomogram at the postoperative 4th month reveals the improvement of the bilateral hydronephrosis. 서구에서는 500 g 이상의 거대 전립선비대증이 다양하게 보고 되어 있다[6,7,20,21]. 하지만 동양인의 전립선이 서양인보다 작기 때문에 동양에서는 거대 전립선비대증에 대한 증례보고는 흔하지 않다. 일본의 경우 270~450 g의 전립선에서 개복전립선절제술을 시행한 사례들이 보고되어 있다[22,23]. 우리나라에서는 Yu 등[24]이 100~203 g의 전립선비대증환자 44명에서 경요도전립선절제술을 시행한 보고가 있고, Kwon 등[25]은100~150 g의 전립선비대증환자 48명을 경요도전립선절제술 또는 개복전립선절제술을 시행 후
거대양성전립선비대증 1 례 145 보고가있지만 300 g 이상의거대전립선비대증에대한보고는아직없다. 개복전립선절제술의전체합병증은일반적으로 10~40% 로보고되고있는데그중출혈이가장대표적인합병증으로수혈을필요로하는경우를 8~9% 로보고하였다 [26]. 저자들의경우에도술중출혈이심해수혈이필요하였으나, 심한출혈에도전립선조직은모두제거되었고출혈로인한다른문제는발생하지않았다. 개복전립선절제술이경요도전립선절제술에비해상대적으로침습적이기때문에최근에는 100 gm 이상에서도레이저를이용한경요도전립선절제술을많이시도하고있다 [27]. 요약거대전립선비대증은삶의질에영향을끼칠뿐만아니라여러가지합병증을유발하여본증례에서처럼생명을위협할수도있다. 약물치료의발전에도불구하고합병증이발생한거대전립선비대증에서는적극적인수술적치료가요구된다. 전립선비대증은더이상서구만의질병이아니다. 배뇨증상이발생한중년이상의남성이라면정기적인전립선검진을통해적절한약물치료또는수술적치료가필요하다. 참고문헌 1. McVary KT, Roehrborn CG, vins L, arry MJ, ruskewitz RC, Donnell RF, et al. Update on U guideline on the management of benign prostatic hyperplasia. J Urol 2011;185:1793-803. 2. Cornu JN. ipolar, monopolar, photovaporization of the prostate, or holmium laser enucleation of the prostate: how to choose what's best? Urol Clin North m 2016;43:377-84. 3. Lee DJ, Rieken M, Halpern J, Zhao F, Pueschel H, Chughtai, et al. Laser vaporization of the prostate with the 180-W XPS-greenlight laser in patients with ongoing platelet aggregation inhibition and oral anticoagulation. Urology 2016;91:167-73. 4. Gopee EL, Hong MK, Pham T. Holmium laser enucleation of the prostate in a 400 cc prostate: case report. J Endourol Case Rep 2016;2:21-3. 5. Madersbacher S, livizatos G, Nordling J, Sanz CR, Emberton M, de la Rosette JJ. EU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (PH guidelines). Eur Urol 2004;46:547-54. 6. Dominguez, Gual J, Munoz-Rodriguez J, bad C, Garcia-Rojo D, Hannaoui N, et al. Giant prostatic hyperplasia: case report of 3987 ml. Urology 2016;88:e3-4. 7. Maliakal J, Mousa EE, Menon V. Giant prostatic hyperplasia: fourth largest prostate reported in medical literature. Sultan Qaboos Univ Med J 2014;14:e253-6. 8. lankstein U, Van sseldonk, Elterman DS. PH update: medical versus interventional management. Can J Urol 2016;23(Suppl 1):10-5. 9. Mmeje CO, Nunez-Nateras R, Warner JN, Humphreys MR. ge-stratified outcomes of holmium laser enucleation of the prostate. JU Int 2013;112:982-9. 10. Wang W, Guo Y, Zhang D, Tian Y, Zhang X. The prevalence of benign prostatic hyperplasia in mainland China: evidence from epidemiological surveys. Sci Rep 2015;5:13546. 11. Kang JY, Min GE, Son H, Kim HT, Lee HL. Nationalwide data on the treatment of PH in Korea. Prostate Cancer Prostatic Dis 2011;14:243-7. 12. Noguchi N, Chan L, Cumming RG, lyth FM, Handelsman DJ, Seibel MJ, et al. Lower urinary tract symptoms and incident falls in community dwelling older men: the concord health and ageing in men project. J Urol 2016. doi: 10.1016/j.juro.2016.06.085. 13. Calais Da Silva F, Marquis P, Deschaseaux P, Gineste JL, Cauquil J, Patrick DL. Relative importance of sexuality and quality of life in patients with prostatic symptoms. Results of an international study. Eur Urol 1997;31:272-80. 14. Clark RV, Hermann DJ, Cunningham GR, Wilson TH,
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