하부요로증상을보인전립선암환자에시행한고식적경요도전립선절제술의배뇨개선효과 The Functional Effect of Palliative Transurethral Resection of the Prostate on Lower Urinary Tract Symptoms in Patients with Prostate Cancer Korean Journal of Urology Vol. 50 No. 5: 445-449, May 2009 DOI: 10.4111/kju.2009.50.5.445 Ho Suck Chung, Chang Min Im, Sun-ouck Kim, Seung Il Jung, Dong Deuk Kwon, Kwangsung Park, Soo Bang Ryu From the Department of Urology, Chonnam National University Medical School, Gwangju, Korea Purpose: Voiding dysfunction occurs frequently in patients with prostate cancer. We investigated the functional effect of palliative transurethral resection of the prostate (pturp) on lower urinary tract symptoms in patients with prostate cancer. Materials and Methods: We retrospectively assessed all patients who had a pturp at our institution between 1999 and 2006. Patients with incidental prostate cancer were excluded. In all, 64 patients were enrolled in the study. The International Prostate Symptom Score (IPSS), the quality of life (QoL), the maximal flow rate (Qmax), and the postvoid residual urine volume (PVR) were evaluated before and after 3 months of pturp. A positive functional outcome was defined as PVR below 100 ml, no additional catheterization, no repeat pturp, and no development of urinary incontinence. Results: The patients' mean age was 76.32±6.8 years, and their mean prostate volume was 46.38±19.43 g. After pturp, the mean IPSS improved from 25.83±6.71 to 18.63±5.96, the mean QoL score improved from 4.33± 0.87 to 3.02±0.83, the mean maximal flow rate increased from 6.11±3.68 ml/sec to 14.20±6.30 ml/sec, and the PVR decreased from 153.69±32.03 ml to 41.89±25.35 ml. All voiding parameters showed significant improvement (p). Of the 64 patients, 12 had poor functional outcome after pturp. The functional improvement rate of pturp was 81.25%. Conclusions: The pturp performed in patients with prostate cancer showed a favorable effect and resulted in significant improvement in voiding dysfunction. In patients with high-stage metastatic prostate cancer or cancer unsuitable for curative therapy, pturp could be considered as a safe treatment method to improve lower urinary tract symptoms. (Korean J Urol 2009;50:445-449) Key Words: Transurethral resection of prostate, Prostatic neoplasms, Treatment outcome 전남대학교의과대학비뇨기과학교실 정호석ㆍ임창민ㆍ김선옥ㆍ정승일권동득ㆍ박광성ㆍ류수방 Received:January 6, 2009 Accepted:April 16, 2009 Correspondence to: Chang Min Im Department of Urology, Chonnam National University Medical School, 8, Hak-dong, Doung-gu, Gwangju 501-757, Korea TEL: 062-220-6700 FAX: 062-227-1643 E-mail: ganglion72@hanmail.net C The Korean Urological Association, 2009 서론전립선암은전세계적으로남성비뇨기계종양중가장흔히진단되는암중의하나이며, 1 최근우리나라에서도노령인구의증가, 식생활의서구화등과함께전립선특이항 원을포함한진단기술의발달로전립선암의발생빈도가현저히증가하고있다. 2,3 전립선내에국한된전립선암은주로근치전립선절제술로치료하나국소적으로진행된혹은원격전이된전립선암은방사선치료, 남성호르몬차단요법이나화학요법을시행한다. 근치적치료가불가능한전이성전립선암환자에서하부요로증상및급성요폐, 방 445
446 Korean Journal of Urology vol. 50, 445-449, May 2009 광결석, 수신증등을동반하는방광출구폐색은흔한합병증으로나타난다. 4,5 전립선비대증에서방광출구폐색은수술적처치로경요도전립선절제술 (transurethral resection of the prostate; TURP) 이표준치료법으로그효과에대하여널리알려져시행되고있지만 6,7 전립선암에서 TURP의효과에대한연구는미비한실정이다. 저자들은하부요로증상을보인전립선암환자에게시행한고식적경요도전립선절제술 (palliative transurethral resection of the prostate; pturp) 의기능적효과를알아보고자하였다. 대상및방법 1999년 1월에서부터 2006년 12월까지본원에서경직장전립선초음파를이용한전립선생검을통하여전립선암으로진단되었으며급성요폐혹은하부요로증상으로경요도전립선절제술을시행받은후 1년이상추적관찰이가능하였던 64명의환자를대상으로의무기록을통해수술시환자의나이, 혈청전립선특이항원 (s-prostate-specific antigen; s- PSA), 경직장전립선초음파에서전립선용적, 임상적병기, 절제된전립선용적, 수술전후의국제전립선증상점수, 삶의질점수, 최대요속, 잔뇨량을후향적으로분석하였다. 대상환자들은임상적병기 ct2 이하인환자에서 80세이상의고령, Eastern Cooperative Oncology Group (ECOG) performance status의 grade 4 이상, 고혈압, 당뇨, 뇌혈관계질환등의동반질환등으로근치전립선절제술을시행하지못한경우와임상적병기가 ct3a 이상인환자의경우에해당되었다. 또한수술후조직검사에서우연히전립선암으로진단된경우는제외하였다. 수술후기능적성공은배뇨후잔뇨량이 100 ml 이하, 1년이내에추가적인요도카테터삽입이나재수술을필요로하지않으며요실금이발생하지않는경우로정의하였다. 8-10 수술은전신마취또는경막외척추마취하에시행하였다. 수술전처치, 수술도구및절제방법은전립선비대증에서의경요도전립선절제술과동일하였으며절제시에전립선피막가까이는절제하지않아피막천공을피하였으며방광출구폐색을완화시켜배뇨통로를확보할정도로시행하였다. 절제된전립선조직은무게를측정한후조직검사를하였다. 술후 22 Fr 도뇨관을이용하여세척하였으며수일후에제거하였다. 통계처리는통계전문상용소프트웨어인 SPSS for windows version 15를이용하여국제전립선증상점수, 삶의질점수, 최고요속, 잔뇨량의수술전후변화에대해 paired t-test를시행하였으며 p 값이 0.05 미만인경우를통계학적으로유의하다고판정하였다. 결 대상환자들의평균연령은 76.3±6.8세, 술전평균전립선용적은 46.38±19.43 g, 평균 s-psa는 48.66±95.83 ng/ml, T2 이하이면서 80세이상의고령이거나, ECOG performance status의 grade 4 이상, 고혈압, 당뇨, 뇌혈관계질환등의동반질환을가진경우로근치전립선절제술에대한수술적인위험도가높은경우는 30명, 술전임상적병기가 ct3a 이상은 34명이었다. 절제된평균전립선용적은 14.4±8.46 g, 술후평균도뇨관유치기간은 5.67±1.77일, 평균입원기간은 9.97±3.29일이었으며도뇨관을재유치한 2명을제외한나머지환자는도뇨관제거후다음날자연배뇨확인후퇴원하였다 (Table 1). 수술전과수술 3개월후의국제전립선증상점수는 25.83±6.71점에서 18.63±5.96점으로감소하였다. 이중배뇨증상점수는 15.63±3.97점에서 9.78±3.86점으로, 저장증상점수는 10.20±3.35점에서 8.84±3.06점으로감소하였다. 삶의질점수는 4.33±0.87점에서 3.02±0.83점으로감소하였으며, 최고요속은 6.11±3.68 ml/s에서 14.20±6.30 ml/s 로증가하였다. 잔뇨량은 153.69±32.03 ml에서 41.89±25.35 ml로감소하여모두통계학적으로의미있는향상을보였다 (p) (Table 2). 또한임상적병기가 ct2 이하인경우와 ct3 이상인경우에서모두의의있는결과를보였다 (p< 0.05) (Table 3). 술후특별한합병증은관찰되지않았으나배뇨후잔뇨량이 100 ml 이상인경우는 8례, 이중에서도뇨관을다시유치한경우는 2례였다. 재수술을받은경우는 5례였는데, 이들은방광경부로의전이가있는경우등진단당시임상적병기가 ct4 이상인환자에해당되었고평균 13.6±6.1개월후에재수술을시행하였으며이중 3례는잔뇨가 100 ml 이상이었다. 요실금은 2례에서발생하였으나추적기간중 Table 1. Patients characteristics (n=64) Age (years) PSA (ng/ml) Prostate volume (g) a Resected chip weight (g) Operative time (min) b Blood loss (ml) Postoperative hospital stay (days) Postoperative catheterization (days) Mean±SD 76.3±6.8 48.66±95.83 46.38±19.43 14.4±8.5 113.9±36.8 85.9±62.5 9.9±3.3 5.7±1.8 SD: standard deviation, PSA: prostate-specific antigen, a : measured by transrectal ultrasonography, b : palliative transurethral resection of the prostate and bilateral orchiectomy, if it was performed 과
Ho Suck Chung, et al:the Functional Effect of Palliative Transurethral Resection of Prostate 447 자연소실되었다 (Table 4). 연구대상인 64례중수술후경과가좋지않은 12례를제외한 52례에서하부요로증상에대한기능적효과가있어고식적경요도전립선절제술의기능적성공률은 81.25% 로조사되었다. Table 2. Comparison of the preoperative and postoperative outcomes IPSS Voiding symptom Storage symptom QoL Qmax (ml/sec) PVR (ml) 고 근치적치료가불가능한전이전립선암환자에서하부요로증상및급성요폐, 방광결석, 수신증등을동반한방광출구폐색은흔한합병증으로관찰되며, 4,5 이에대한호르몬치료의효과는여러연구에서보고되었다. Hand 11 에의하면급성요폐전립선암환자에서호르몬치료만으로자연배뇨가가능하였다고하였으며, Chute 등 12 은 13명의급성요폐환자에서 9명이고환절제술후자연배뇨가가능하였으며, 추적관찰결과전립선암의크기또한감소하였다고보고하였다. Fleischmann과 Catalona 13 는 35명의요폐증상을보인전립선암환자에서고환절제술을시행한후에 24명 (68%) 이자연배뇨가가능하였으나, 이중절반가량에서는 21일에서 60일동안요도카테터를통하여배뇨하였다고보고하였다. 전립선암환자에서호르몬치료는방광출구폐색을완화시키고전립선의크기를감소시킬수있지만많은시 Preoperative Postoperative p-value 25.83±6.71 15.63±3.97 10.20±3.35 4.33±0.87 6.11±3.68 153.69±32.03 18.63±5.96 9.78±3.86 8.84±3.06 3.02±0.83 14.20±6.30 41.89±25.35 IPSS: International Prostate Symptom Score, QoL: quality of life, Qmax: maximal urine flow rate, PVR: postvoid residual urine volume 찰 간이소요된다는한계점이있다. 14,15 그럼에도불구하고최근까지고식적경요도전립선절제술은수술에대한부정적인인식으로전립선암환자에서발생한요폐에대한일차적인치료방법으로고려되지못하였다. 16 Pergament 등 17 은전립선암환자에서술중및술후의출혈경향과파종성혈관내응고 (disseminated intravascular coagulopathy) 의위험성에관하여보고한바있으나, 최근보고에의하면고식적경요도전립선절제술은전립선비대증환자에서시행한경요도전립선절제술과비교하여실혈량, 재원기간, 합병증등에의의있는차이를보이지않고안전하게시행될수있었으며, 18,19 Crain 등 19 은전이전립선암환자에서의수혈은술중실혈에의한것보다술전악성빈혈이원인일수있음을주장하였다. 또한고식적경요도전립선절제술이전립선암의진행에부정적인영향을미칠수있다는일부연구결과가보고되었으나, 20-22 이에대한가능성은명확하지않으며근거또한충분하지못하다. Pansadoro 등 23 은전립선암에서의경요도전립선절제술은암의전이를증가시키지않는다고하였으며, Nativ 등 24 과 Paul 등 25 은전립선생검을통하여진단된환자와경요도전립선절제술에의해우연히진단된전립선암에서경요도전립선절제술이전립선암의진행에영향을미치지않는다고주장하였다. 이밖에여러연구에서고식적경요도전립선절제술의긍적적인결과가보고되었으며 Table 4. Poor outcomes after palliative transurethral resection of the prostate (n=12) Poor outcomes Case (%) Postvoid residual urine volume >100 ml Re-catheterization Re-operatiosn a Urinary incontinence 8 (12.5) 2 (3.1) 5 (7.8) 2 (3.1) a : three patients had postvoid residual volume of >100 ml before re-operation Table 3. Comparison of the preoperative and postoperative outcomes between the 2 groups IPSS Voiding symptom Storage symptom QoL Qmax (ml/sec) PVR (ml) Group I ( ct2) Group II ( ct3) Preoperative Postoperative p-value Preoperative Postoperative p-value 23.63±6.71 14.67±4.21 8.97±3.40 4.13±0.68 6.33±3.27 133.93±31.02 17.30±6.12 9.27±4.17 8.03±3.06 2.87±0.82 13.43±6.01 37.57±23.15 0.004 27.76±6.06 16.47±3.60 11.29±2.94 4.50±0.99 5.93±4.06 171.12±36.33 19.79±5.65 10.24±3.58 9.56±2.93 3.15±0.82 14.87±6.56 45.71±28.31 0.001 IPSS: International Prostate Symptom Score, QoL: quality of life, Qmax: maximal urine flow rate, PVR: postvoid residual urine volume
448 Korean Journal of Urology vol. 50, 445-449, May 2009 방광출구폐색이있는전립선암환자에서안전하게시행될수있다는것이입증되었다. 26-29 전립선암에시행한고식적경요도전립선절제술의기능적결과에대하여는몇몇연구에서보고된바있다. 8-10 Marszalek 등 8 은 89명의환자를대상으로한번의수술후에약 75% 가성공적인결과를보였으며평균 2.6년의추적관찰기간으로 79% 의환자에서특별한문제없이자연배뇨를하였다고하였으며, Gnanapragasam 등 9 도 46명의환자중약 61% 가술후 39개월의추적기간에서긍정적인결과를보였다고하였다. 본연구에서는 81.25% 의높은배뇨개선효과를보였고이러한성공률의차이는몇가지원인에의한것으로생각한다. 저자들의경우 64명의환자들중 43명에서고식적경요도전립선절제술과고환절제술을동시에시행하였고, 방사선치료후하부요로증상을보인환자는 2 명에불과하였다. Varenhorst와 Alund 14 는요폐가있는전립선암환자에서외과적및내과적호르몬치료모두효과적이었으나고환절제술을시행한환자에서약물치료로만시행한경우보다자연배뇨까지의기간이단축되었다고하였으며 Gnanapragasam 등 9 과 Crain 등 10 은방사선치료가수술후기능적결과에부정적인영향을줄수있다고보고한바있는데이와같은결과가본연구에영향을주었을것으로생각한다. 또한술후배뇨기능에영향을줄수있다고알려진호르몬불응성전립선암환자 9 가대상에포함되지않은것도높은성공률을보이는원인으로생각한다. 이전의보고에서는후향적연구로인하여술전후의기능적결과에대한객관적인자료가부족하였다. 8,9 Marszalek 등 8 은대부분의환자들이수술에대한강력한적응증을가지고있어국제전립선증상점수및요속검사를모든환자에게시행하지는못하였다고하였으며, Gnanapragasam 등 9 도수술에대한결정이환자의증상과장기간요도카테터유치를피하기위한것이었기때문에객관적자료가부족하였다. 그러나저자들의경우환자들의하부요로증상에대하여수술전후의국제전립선증상점수, 삶의질점수, 최대요속및잔뇨량검사를모든환자들을대상으로시행하였고수술전과후를비교하였으며이러한점이다른연구들과차별되는의의로생각한다. 그러나일차적인호르몬치료후부터수술을시행한시기까지의기간에대한요인을고려하지않은것은본연구의한계점으로생각한다. 저자들은술후 3개월에시행한기능적성공에대한결과는만족스러웠으며대부분의환자들은술후배뇨에대하여큰불편감없이추적관찰중이며, 고식적경요도전립선절제술을요하는전립선암환자를예측할수있는술전위험인자에대한분석, 전립선암의진행정도에따른술후기능적결과의비교분석역시연구가치가있을것으로생각한다. 결 저자들이시행한하부요로증상을보인전립선암환자에서의고식적경요도전립선절제술은특별한합병증을보이지않고 81.25% 의높은성공률을보였다. 이는고식적경요도전립선절제술이전립선암의병기가높거나근치적수술을받기어려운상태의전립선암환자들에게안전하며하부요로증상완화에효과적인치료방법의하나로생각한다. 론 REFERENCES 1. Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43-66 2. Choe JH, Lee HM, Chai SE, Choi HY. Long-term healthrelated quality of life in patients with prostate cancer after treatment. Korean J Urol 2004;45:878-89 3. Lee HW, Kwak KW, Choi YH, Choi HY, Lee HM. New thresholds for prostate-specific antigen velocity for prostate cancer screening in Korean patients younger than 60 years old. Korean J Urol 2008;49:113-7 4. Moul JW, Davis R, Vaccaro JA, Sihelnik SA, Belville WD, McLeod DG. Acute urinary retention associated with prostatic carcinoma. J Urol 1989;141:1375-7 5. Scherr D, Swindle PW, Scardino PT. National Comprehensive Cancer Network guidelines for the management of prostate cancer. Urology 2003;61(2 Suppl 1):14-24 6. Varkarakis J, Bartsch G, Horninger W. Long-term morbidity and mortality of transurethral prostatectomy: a 10-year followup. Prostate 2004;58:248-51 7. Djavan B, Madersbacher S, Klingler HC, Ghawidel K, Basharkhah A, Hruby S, et al. Outcome analysis of minimally invasive treatments for benign prostatic hyperplasia. Tech Urol 1999;5:12-20 8. Marszalek M, Ponholzer A, Rauchenwald M, Madersbacher S. Palliative transurethral resection of the prostate: functional outcome and impact on survival. BJU Int 2007;99:56-9 9. Gnanapragasam VJ, Kumar V, Langton D, Pickard RS, Leung HY. Outcome of transurethral prostatectomy for the palliative management of lower urinary tract symptoms in men with prostate cancer. Int J Urol 2006;13:711-5 10. Crain DS, Amling CL, Kane CJ. Palliative transurethral prostate resection for bladder outlet obstruction in patients with locally advanced prostate cancer. J Urol 2004;171:668-71 11. Hand JR. Conservative operations for carcinoma of the prostate: analysis of 109 cases. J Urol 1950;64:123-48 12. Chute R, Willetts AT, Gens JP. Experiences in the treatment of carcinoma of the prostate with stilbestrol and with castration by the technique of intra-capsular orchiectomy. J Urol 1942; 48:682
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