76 소아외과 : 제 13 권제 1 호 2007 년 Vol. 13, No. 1, June 2007 잔존총배설강기형수술후발생한요도 - 질누공에대한전방시상경직장적접근술식 (Anterior Sagittal Transrectal Approach, ASTRA) 1 례보고 연세대학교의과대학외과학교실, 세브란스어린이병원소아외과 김성민 김창우 김병규 오정탁 한석주 서 론 로결찰하였기에증례를보고하고자한다. 요도-질누공은총배설강기형의교정수술후발생하는주요합병증중의하나이며 1 요로감염을자주유발하고질및방광내에결석이발생하므로수술적으로교정하여야한다. 질을통한접근법은질의내경이작아시야확보가어렵고누공이구부요도이상의방광경부에존재하는경우질을통해서는누공에접근하기가불가능하다. 질과방광사이의벽은매우얇고연약하여수술시손상받기쉬우며, 양측요관의상당한부분은이곳을지나가기때문에개복하여누공에접근하는경우방광및요관의손상을유발하며, 오랜수술시간과고난도의술기를요한다 2. 이에저자들은전방시상경직장적접근법을이용하여총배설강기형교정수술후발생한요도-질누공을성공적으 본논문의요지는 2006 년 11 월 3 일제 58 차대한외과학회추계통합학술대회에서구연되었음. 접수일 : 07/3/16 게재승인일 : 07/5/28 교신저자 : 한석주, 120-752 서울특별시서대문구신촌동 134 연세대학교의과대학외과학교실소아외과 Tel : 02)2228-2130, Fax : 02)313-8289 E-mail: sjhan@yumc.yonsei.ac.kr 증례환자는 3년 6개월여자환자이다. 출생직후잔존총배설강, 중복자궁, 중복질로진단되어결장루조성술을시행후생후 22개월에교정수술 ( 후방시상항문직장성형술, 우측자궁-질절제술, 좌측자궁-질의회음부전환술 ) 을시행받았다 ( 그림 1). 술후반복적인요로감염과전환된질내의결석으로인하여수차례입원하여항생제치료를받고방광경을이용하여결석을제거하였다. 방광경검사로좌측의전환된질과방광경부요도사이에생긴누공을발견하였으며전방시상경직장적접근법으로요도-질누공의봉합에성공하였다. 전신마취하에도뇨관삽입후 Jack-Knife 자세로직장전벽에약 7cm의절개를가한다음질의후벽과질의전벽을차례로절개한후누공을통하여수술전요로에삽입한도뇨관을관찰할수있었다. 요도-질누공의변연부를확보한후흡수성봉합사 (Vicryl) 를이용하
김성민외 : 요도 - 질누공에대한전방시상경직장적접근술식 77 Fig. 1. A, cystogram showing double uterus, vagina (long arrow) and bladder (short arrow); B, gross finding of persistent cloaca after opening of common channel (Upper part of the picture shows coccyx). 하였다. 수술후회음부로전환된질을통한배뇨현상은관찰되지않았고수술후 52일째시행한배설성방광요도조영술상기존에관찰되었던요도-질누공은관찰되지않았다 ( 그림 3). 고 찰 Fig. 2. Photograph of operative field in ASTRA (modified Jack-knife position). Anterior rectal wall is divided into two lateral walls. Posterior vaginal wall is also divided and retracted by holding suture material (black silk). After careful inspection of the anterior vaginal wall, fistula tract is found (asterisk). It is retracted by several holding sutures (prolene) for repair (interrupted absorbable suture). Inset: Original discription of ASTRA of Domini, et al. (2000) 여누공을폐쇄봉합하였다 ( 그림 2). 수술시간은 5시간 46분이소요되었으며출혈은경미하였다. 도뇨관은수술후 10일동안유지하였으며환자는수술후 12일째퇴원 선천성항문직장기형에대하여 Pena 와 de Vries 등이후방시상항문직장성형술을시행한이후로 1982년처음으로잔존총배설강에대하여서도이수술법이적용되었다 1. 그러나직장과질의분리, 요도와질의분리를시행하는데, 요도와질의경계는모호하며매우얇고연약하며단일한층으로되어있어구분이명확하지않으므로분리에고난이도의술식및오랜수술시간을요한다 1,3. 특히총배설강의길이가 3cm 이상이되는긴공통관 (long common channel) 인경우요도와질을분리하고질입구를회음부까지하강시키는것은매우어려운작업
78 소아외과제 13 권제 1 호 2007 년 Fig. 3. Pre (A) and post (B)-operative voiding cystourethrogram: A, urethrovaginal fistula is shown (asterisk). Neovagina is filled with contrast dye (arrow); B, voiding cystourethrogram after repair of urethrovaginal fistula by ASTRA. The fistulous tract is disappeared (arrow). 이며종종불가능한경우도있으므로질의하강을위하여몇가지방법즉피부판을이용한방법, 장관을이용한방법, 질편을이용한방법등이고안되었다 2. Pena 1 (1989) 는 54례의잔존총배설강수술후 6예에서요도-질누공이발생되었다고하며질벽의허혈성손상이요도-질누공의발생의가장중요한원인이라고하였고 1997년처음으로요도와질을분리하지않고회음부로하강시키는 Total Urogenital Mobilization 술식을시행하여요도-질누공의발생을최소화하였다 4. Total Urogenital Mobilization 술식은총배설강의공통관이 3 cm이하인경우좋은치료성적을보이고있으나공통관이긴경우나생식기관의고도기형이동반된경우는불가능하다. 요도-질누공의증상은반복적인요로감염, 질내결석, 질을통한소변배출등이다. 발생원인으로는기술적인측면즉요도-질분리수술시장력발생, 허혈성손상, 요로-방광경부의미세천공등을먼저생각할수있다. 잔존총배설강은해부학적으로복잡하고다양한유형의 구조를가지고있으므로교정수술시마취종료전에방광요도조영술및질조영술을시행하는것이좋으며수술중요로계의손상을막기위하여, 너무깊이요도와질을분리하는것보다는질전환술을하는것이요도-질누공의발생을막을수있는방법중하나이다 1. Pena 1 (1989) 는기술적으로혈관이풍부한질외벽을전벽으로회전시켜요도바로뒤에위치시키는방법과총배설강의후벽을재건하여요도를만들때꼭전층을안정되게봉합하는방법을제안하였다. Pena 등 5 (1992) 이실시한후방시상접근법은직장의전벽과후벽을모두절개하여비뇨생식동굴에접근하였고항상장루조성술을같이시행하였다. 그러나 Domini 등 6 (1997) 이고안한전방시상경직장적접근법은직장의전벽만절개하기때문에직장의재건과관련한합병증을최소화하고, 장루가필요하지않고, 동시에비뇨생식기에대하여좋은수술시야를확보할수있으며외상에의한재발성요도-질누공환자에대하여시행하여좋은치료효과를얻었다고
김성민외 : 요도 - 질누공에대한전방시상경직장적접근술식 79 한다 7. 본증례의환자의경우결장루가있는상태에서누공봉합수술을시행하였기때문에변배출에의한합병증이없었으며 Domini 등 6 (1997) 의증례및의견과는달리잔존총배설강교정수술후발생한요도-질누공을수술할때는반드시장루를만들어주어야한다고생각된다. 장루가없는상태로수술할경우오랜금식및총경정맥영양을필요로할것이다. ASTRA는개복술이나질을통한접근법에비하여요도-질누공으로접근이용이하고수술시야가좋아수술시누공을조기에발견할수있었으며방광과질벽경계부의요관손상을최소화할수있다. 또한직장의전방부만절제한후재건하기때문에직장재건과관련한합병증및수술후배변기능이악화될가능성이적다. 저자들이경험한잔존총배설강기형의수술후발생한요도-질누공에대한전방시상경직장적수술법은안전하고간편하며효과적인방법이라사료된다. 참고문헌 1. Pena A: The surgical management of persistent cloaca: results in 54 patients treated with a posterior sagittal approach. J Pediatr Surg 24:590-598, 1989 2. Pena A, Levitt MA, Hong A, Midulla P: Surgical management of cloacal malformations: a review of 339 patients. J Pediatr Surg 39:470-479; discussion 470-479, 2004 3. Shimada K, Hosokawa S, Matsumoto F, Johnin K, Naitoh Y, Harada Y: Urological management of cloacal anomalies. Int J Urol 8:282-289, 2001 4. Pena A: Total urogenital mobilization--an easier way to repair cloacas. J Pediatr Surg 32:263-267; discussion 267-268, 1997 5. Pena A, Filmer B, Bonilla E, Mendez M, Stolar C: Transanorectal approach for the treatment of urogenital sinus: preliminary report. J Pediatr Surg 27:681-685, 1992 6. Domini R, Rossi F, Ceccarelli PL, De Castro R: Anterior sagittal transanorectal approach to the urogenital sinus in adrenogenital syndrome: preliminary report. J Pediatr Surg 32:714-716, 1997 7. Domini M, Aquino A, Rossi F, Lima M, Ruggeri G, Domini R: Recurrent posttraumatic urethrovaginal fistula: a new application for ASTRA. J Pediatr Surg 35:522-525, 2000
80 소아외과제 13 권제 1 호 2007 년 Anterior Sagittal Transrectal Approach (ASTRA) for Urethrovaginal Fistula after Total Repair of Persistent Cloaca - 1 Case Report - Seong Min Kim, M.D., Chang Woo Kim, M.D., Byoung Kyu Kim, M.D., Jung-Tak Oh, M.D., Seok Joo Han, M.D. Division of Pediatric Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea The authors applied anterior sagittal transrectal apporach (ASTRA) for the repair of urethrovaginal fistula which developed after total repair of persistent cloaca. The patient had been diagnosed to have persistent cloaca, double uterus and double vagina, and received PSARP, excision of right-side uterus and vagina, and left vaginal switch operation at 22 months old. After operation, the patient admitted several times due to frequent urinary tract infection and ectopic stone formation in bladder and neovagina. Urethro-neovaginal fistula was confirmed by cystoscopy and corrected with ASTRA. Postoperative voiding cystourethrogram showed no fistula tract. ASTRA showed improved surgical field, minimized ureterocystic damage, and preserved perirectal nerve due to limited incision of rectum. (J Kor Assoc Pediatr Surg 13(1):76~80), 2007. Index Words:Cloaca, Urethrovaginal fistula, Anterior sagittal transrectal approach (ASTRA), Posterior sagittal anorectourethrovaginoplasty (PSARUVP), Total urogenital mobilization Correspondence:Seok Joo Han, M.D., Division of Pediatric Surgery, Department of Surgery, Yonsei University College of Medicine, #134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea Tel : 02)2228-2130, Fax : 02)313-8289 E-mail: sjhan@yumc.yonsei.ac.kr