Case Report pissn 1738-2637 / eissn 2288-2928 J Korean Soc Radiol 2017;76(2):158-164 https://doi.org/10.3348/jksr.2017.76.2.158 Injectable Bulking Agents for Urinary Incontinence after Radical Prostatectomy, Mimicking Local Recurrence: A Case Report 근치전립선절제술후발생한요실금환자에서재발전립선암으로오인된요도주위확장성약물주사의영상소견 : 증례보고 Jehong Yoon, MD 1, Sung Eun Ahn, MD 1, Sung Kyoung Moon, MD 1, Seong Jin Park, MD 1, Joo Won Lim, MD 1 *, Sun Ju Lee, MD 2 Departments of 1 Radiology, 2 Urology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea Periurethral bulking agent injection (or transurethral submucosal injection) is a comparatively less invasive procedure for the treatment of stress urinary incontinence in patients who develop incontinence after radical prostatectomy, and who are more frequently being treated with transurethral submucosal injection. However, as the radiologic findings of bulking agents are not very well known, they can be mistaken for local recurrence in prostate cancer patients who have undergone prostatectomy. Unlike some of the literatures, in which the radiologic features of collagen injections have been reported, the radiologic findings of silicone injections are yet to be determined. Thus, it is our intention to report this case along with the literature review as the authors have experienced an actual case of a silicone injection mistaken as local recurrence. Index terms Prostatic Neoplasms Urinary Incontinence, Stress Urinary Sphincter, Artificial Received February 3, 2016 Revised May 17, 2016 Accepted August 12, 2016 *Corresponding author: Joo Won Lim, MD Department of Radiology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea. Tel. 82-2-958-8618 Fax. 82-2-968-0787 E-mail: uroradiolim@dreamwiz.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 최근수년간전립선절제수술방법의발전에도불구하고전립선절제술후요실금 (postprostatectomy urinary incontinence) 은여전히흔한수술후합병증으로, 남성에서발생하는복압요실금의가장흔한원인으로알려져있다. 전립선암이나전립선비대증의발생빈도증가에따른수술적치료증가에따라자연히남성요실금치료의중요성이부각되고있으며, 요도주위확장성약물주사 (transurethral submucosal injection 또는 periurethral bulking agents injection), 걸기시술 (sling procedures), 조절형풍선시술 (adjustable balloon system), 인공방광조임근시술 (artificial sphincter) 등다양한치료방법이시행되고있으나현재최적의치료방법으로밝혀진것이없고 (1), 치료방법에대 한영상소견이많이알려지지않은실정이다. 저자들은전립선암으로근치전립선절제술 (radical prostatectomy) 후에발생한요실금으로요도주위확장성약물주사를받은환자의영상검사에서확장성약물인실리콘을전립선암의국소재발로오인하였던증례를경험하였는데, 일부문헌에서콜라겐주사약물의영상소견이보고되어있는것과달리 (2-5), 실리콘주사약물의영상소견은아직까지보고된바없어이를문헌고찰과함께보고하고자한다. 증례보고 환자는 64 세남자로 2000 년 7월에전립선암으로후치골접근법 (retropubic approach) 을이용한근치전립선절제술 (T2b- 158 Copyrights 2017 The Korean Society of Radiology
윤제홍외 N0M0, Gleason score 4+4) 을받았다. 추적관찰중 2004 년 에전립선특이항원 (prostate specific antigen; 이하 PSA) 이상승 하여호르몬치료 (leuprolide acetate) 를하였으나호전되지않 아 positron emission tomography-computed tomography 를시 행하였으며, 우측엉덩림프절전이가발견되어, 총 6000 cgy 의 방사선치료를받았다. 이후환자는외래에서정기적추적관찰 A B C D E F A, B. Axial CT images show well-defined, peripheral enhancing nodular lesions around the vesicourethral anastomosis (arrows). C, D. Coronal CT images show well-defined, peripheral enhancing nodular lesions around the vesicourethral anastomosis (arrows). E, F. T2-weighted oblique axial images of prostate MRI show a relatively well-defined nodular lesion with irregular thick walls and internal contents with high signal intensity (arrows). jksronline.org 대한영상의학회지 2017;76(2):158-164 159
근치전립선절제술후발생한요실금환자에서재발전립선암으로오인된요도주위확장성약물주사의영상소견 G H I J K G, H. T2-weighted coronal images of prostate MRI show a relatively well-defined nodular lesion with irregular thick walls and internal contents with high signal intensity (arrows). I-K. T2-weighted sagittal images of prostate MRI show a relatively well-defined nodular lesion with irregular thick walls and internal contents with high signal intensity (arrows). 160 대한영상의학회지 2017;76(2):158-164 jksronline.org
윤제홍외 을하였는데 2011년과 2013 년, 2014 년에 PSA 가각각 26.02 ng/ml, 14.71 ng/ml, 13.29 ng/ml 로다시증가하여시행한 CT에서대동맥주변림프절전이가확인되어다시호르몬치료후 PSA 가정상화되었던병력을갖고있었다. 2015 년 8월에시행한 CT에서림프절전이이외에도방광-요도연결부 (vesicourethral anastomosis) 주변으로연조직음영의병변들이새롭게관찰되었는데, 각각의병변들은방광-요도연결부의 1시, 5시, 7시방향에위치하면서약 1.9 cm 크기의테두리조영증강 (peripheral rim-like enhancement) 을보이는연 조직음영의종괴였으며 (Fig. 1A-D), 전립선암의국소재발 (local recurrence) 가능성을배제할수없었기때문에전립선 MRI 를시행하였다. 전립선 MRI 의 T2 강조영상에서이들병변은 CT와같은위치에서균질한고신호강도를갖는병변들로나타났으며, 병변의주변부로조영증강되는저신호강도의띠를가지고있었다. 확산강조영상에서확산제한소견이없었으며, 역동적조영증강영상에서도조영증강되지않아 (Fig. 1E-Q) 전립선암의국소재발의영상소견과는부합하지않는소견을보였다. L M N L, M. On T1-weighted oblique axial images, the nodular lesions show homogeneous iso to low signal intensity (arrows). N, O. Diffusion weighted images show no evidence of diffusion restriction (arrows). O jksronline.org 대한영상의학회지 2017;76(2):158-164 161
근치전립선절제술후발생한요실금환자에서재발전립선암으로오인된요도주위확장성약물주사의영상소견 환자의의무기록을살펴본결과, 환자는추적관찰기간중발생한요로및방광결석으로수차례쇄석술을시행받았으며, 역행요도조영술 (retrograde urethrography) 에서방광-요도연결부협착 (vesicourethral anastomosis stricture) 이확인되어 2014 년에요도경요도절개술 (urethroscopic urethrotomy) 을받은이후, 지속적인복압요실금증상을호소하여, 실리콘 (Macroplastique ; Cogentix Medical, Inc., Minnetonka, MN, USA) 을이용한요도주위확장성약물주사시술을받은병력이있었으며, MRI 에서방광요도연결부의병변들은의무기록을통해서확장성주입약물에의한소견이었던것임을알수있었다. 이후환자는가장최근까지의추적검사에서림프절전이에따른 PSA 증가소견 (21.78 ng/ml) 은큰변화없이경과관찰중이며, 복압요실금은호전된상태를유지하고있다. 고찰 전립선절제술후요실금은최근수년간의수술방법의발전에도불구하고여전히흔하게발생하는수술후합병증으로, 남성에서발생하는복압요실금의가장흔한원인으로알려져있으며 (6), 완전요실금 (total urinary incontinence) 은 0~17% 에서발생하고, 그중에서복압요실금은 0~35% 까지동반되는것으로보고되어있다 (7). 전립선절제이후에발생하는요실금의정확한원인으로밝혀진것은없으나, 수술후약 0~32% 에서발생한다고보고되어있는방광목기능이상 (bladder neck dysfunction), 방광목조임근결핍 (urethral sphincter deficiency), 혹은두가지모두가요실금의원인과관련이있다고생각되며, 또한증상의악화와수술적치료를어렵게만드는요소로작용한다고알려져있다 (1). 전립선암이나양성전립선비대증의발생빈도증가와그에따른수술적치료의증가에따라자연히남성복압요실금의수술적치료의중요성이부각되고있으며, 요도주위확장성약물주사, 걸시시술 (sling procedures), 조절형풍선시술 (adjustable balloon system), 인공방광조임근시술 (artificial sphincter) 등다양한치료방법이제시되고있는데, 가장많이시행되는것은요도주위확장성약물주사와인공방광조임근시술이다 (7). 요도주위확장성약물주사는침습정도가낮은요실금의치료방법중의하나로, 주된적응증은외요도괄약근 (external sphincter) 의내인성기능부전 (intrinsic insufficiency) 이다. 콜라겐 (Contigen ; Bard medical, Inc., Covington, GA, USA), 실리콘 (Macroplastique ; Cogentix Medical, Inc.) 또는 NASHA/ Dx copolymer (Deflux ; Salix Pharmaceuticals, Inc., Raieigh, NC, USA) 등이사용되고있으며, 외요도괄약근부근에주사한다. 요도주위확장성약물주사는 Tamanini 등 (8) 이제시한방법에따라 2시와 6시, 10 시방향으로약물을주사하는방법이주로사용되고있는데, 일부에서는환형으로약물주사 (circumferential distribution) 를하는것이더효과적이라는보고도있다 (9). 본증례에서사용된실리콘은 polydimethylsiloxane silicon elastomer 를 polyvinylpyrrolidone carrier gel 과함께주사하는 P Q P, Q. Dynamic contrast-enhanced images show peripheral enhancement of the nodular lesions after 210 seconds of contrast material injection (arrows). 162 대한영상의학회지 2017;76(2):158-164 jksronline.org
윤제홍외 고점액성물질 (highly viscous material) 로육아종을만들지않는인체에적합한물질 (biocompatible material) 로알려져있다. 전립선암으로근치전립선절제술을받은환자에서생화학적재발 (biochemical recurrence) 은흔하며, 특히고위험전립선암 (high-risk prostate cancer) 에서그러하다. 근치전립선절제술이후전립선암의국소적재발을진단하기위해서는다양한파라미터 (multi-parametric) 의 MRI 가필요하며, 이를통해서민감도와특이도를향상시킬수있다. 전립선암의재발은 T2 강조영상에서뚜렷한고신호강도및 T1 강조영상에서주변근육조직과비슷한정도의신호강도를보이는분엽성외형을갖는종괴로나타난다. 역동적조영증강 MRI 에서전립선암의국소재발은조기동맥기조영증강 (early arterial enhancement) 을나타내기때문에, 수술부위주변에발생한섬유화 (fibrosis) 또는남아있는전립선비대결절 (residual benign prostatic hyperplastic nodule) 과감별이가능하다. 국소재발병변은확산강조영상에서확산제한을나타낸다. Sella 등 (10) 의연구에의하면국소재발은방광후부 (retrovesical area, 40%), 방광-요관연결부위 (peri-anastomotic area, 29%), 잔류정낭 (retained seminal vesicle, 22%), 그리고수술부위경계 (surgical margin) 의전방또는측면 (9%) 순으로많이발생하는것으로보고되어있다. 콜라겐은 MRI T1과 T2 강조영상모두에서경계가좋은저신호에서중등도신호강도의결절 (nodule) 형태를보여, 항문거근 (levator ani) 이나속폐쇄근 (obturator internus muscle) 과비슷한정도의신호강도를보이는전립선암재발병소와감별이가능하다는보고가있으나 (2-5), 본증례에서사용된실리콘에대한영상소견은알려진바가없다. 실리콘은 CT에서비교적경계가잘구분되면서주변부조영증강을보이는원형혹은타원형의종괴로관찰되는데 (Fig. 1A-D), 본증례에서와같이임상적으로재발가능성이강하게의심되는환자에서 CT 소견만을가지고그가능성을완전히배제하기에는어려움이있을것으로생각된다. 하지만, 전립선 MRI 의 T2 강조영상에서는비교적균질한내부고신호강도를보이는경계가좋은원형혹은타원형의병변으로보이며, 주변부는조영증강및낮은신호강도를보이게된다 (Fig. 1E-K). T1 강조영상에서는병변전체가균질한저신호강도를보이며 (Fig. 1L, M), 확산강조영상에서확산제한소견을보이지않고 (Fig. 1N, O), 역동적조영증강영상에서조영증강소견을보이지않음으로써 (Fig. 1P, Q), 전립선암의국소재발과구분되는소견을보인다. 결론적으로, 전립선암으로근치전립선절제술을받은환자의추적영상검사에서재발병변이의심되는경우, 환자의의무기 록을면밀히검토하여요도주위확장성약물주사시술을받았는지를파악할필요가있으며, 병변의분포위치와영상소견을주의깊게참고함으로써확장성약물주사에의한병변을전립선암의재발로진단하는실수를피할수있다. REFERENCES 1. King T, Almallah YZ. Post-radical-prostatectomy urinary incontinence: the management of concomitant bladder neck contracture. Adv Urol 2012;2012:295798 2. Maki DD, Banner MP, Ramchandani P, Stolpen A, Rovner ES, Wein AJ. Injected periurethral collagen for postprostatectomy urinary incontinence: MR and CT appearance. Abdom Imaging 2000;25:658-662 3. Kumar D, Kaufman MR, Dmochowski RR. Case reports: periurethral bulking agents and presumed urethral diverticula. Int Urogynecol J 2011;22:1039-1043 4. Bridges MD, Petrou SP, Lightner DJ. Urethral bulking agents: imaging review. AJR Am J Roentgenol 2005;185: 257-264 5. Yablon CM, Banner MP, Ramchandani P, Rovner ES. Complications of prostate cancer treatment: spectrum of imaging findings. Radiographics 2004;24 Suppl 1:S181-S194 6. Doherty R, Almallah Z. Urinary incontinence after treatment for prostate cancer. BMJ 2011;343:d6298 7. Shekarriz B, Upadhyay J, Wood DP. Intraoperative, perioperative, and long-term complications of radical prostatectomy. Urol Clin North Am 2001;28:639-653 8. Tamanini JT, D Ancona CA, Tadini V, Netto NR Jr. Macroplastique implantation system for the treatment of female stress urinary incontinence. J Urol 2003;169:2229-2233 9. Defreitas GA, Wilson TS, Zimmern PE, Forte TB. Three-dimensional ultrasonography: an objective outcome tool to assess collagen distribution in women with stress urinary incontinence. Urology 2003;62:232-236 10. Sella T, Schwartz LH, Swindle PW, Onyebuchi CN, Scardino PT, Scher HI, et al. Suspected local recurrence after radical prostatectomy: endorectal coil MR imaging. Radiology 2004;231:379-385 jksronline.org 대한영상의학회지 2017;76(2):158-164 163
근치전립선절제술후발생한요실금환자에서재발전립선암으로오인된요도주위확장성약물주사의영상소견 근치전립선절제술후발생한요실금환자에서재발전립선암으로오인된요도주위확장성약물주사의영상소견 : 증례보고 윤제홍 1 안성은 1 문성경 1 박성진 1 임주원 1 * 이선주 2 요도주위확장성약물주사 (periurethral bulking agents injection 또는 transurethral submucosal injection) 는비교적덜침 습적으로복압요실금 (stress urinary incontinence) 을치료할수있는방법으로, 전립선절제술이후에발생한요실금환자 에서그사용빈도가증가하고있다. 그러나이러한요도주위확장성약물주사의영상소견에대해알려진문헌이많지않으 며, 특히실리콘을이용한약물주사의영상소견은알려진바가없어, 전립선암으로근치전립선절제술을받은환자의경우 국소재발로오인될수있다. 저자들은실리콘요도주위확장성약물주사치료를받은환자에서국소재발로오인하였던증 례를경험하여, 이에대한영상소견과함께보고하고자한다. 경희대학교의학전문대학원 / 의과대학경희대학교병원 1 영상의학과, 2 비뇨기과 164 대한영상의학회지 2017;76(2):158-164 jksronline.org