ORIGINAL ARTICLE Korean J Obstet Gynecol 2011;54(2):93-98 doi: 10.5468/KJOG.2011.54.2.93 pissn 2233-5188 eissn 2233-5196 PREDICTING RISK FACTORS OF POSTOPERATIVE VOIDING DYSFUNCTION AFTER ABDOMINAL SACROCOLPOPEXY IN THE TREATMENT OF PELVIC ORGAN PROLAPSE Su Yeon Park, MD, Ha Yan Kwon, MD, Jung Hwa Park, MD, Yeo Jung Moon, MD, Sei Kwang Kim, MD, Sang Wook Bai, MD Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea Objective Although there were many studies about postoperative voiding dysfunction after anti-incontinence operation, little studies after pelvic organ prolapse operation were published. We sought to determine risk factors for voiding dysfunction (VD) after abdominal sacrocolpopexy (ASC). Methods ASC was performed on 89 women at Yonsei University Health System from January 2007 to December 2009. VD was defined as post void residual (PVR)>150 ml. Foley catheter was removed after the third or forth postoperative day (POD). Risk factors for VD were examined using logistic regression models. Results Seventeen patients (19.1%) had VD. Total abdominal hysterectomy (TAH) was performed on 70.8%, transobturator tape (TOT) on 55.1% concomitantly. There was no significant difference in age (mean± standard deviation [SD], 59.9±12.8 vs. 62.7±8.1 yr), parity (mean [range], 3 [1-5] vs. 3 [1-8]), body mass index (mean±sd, 24.0±2.7 vs. 24.4±3.6), TAH (70.6% vs. 70.8%), TOT (52.9% vs. 55.6%) and pelvic organ prolapse quantification stage 4 (94.1% vs. 68.1%, P-value 0.057). There was significant difference in diabetes mellitus (29.4% vs. 9.7%, odds rations [OR]: 3.87 [95% confidence intervals, CI: 1.05-14.23]) and the day of foley removal (POD 4: 47.1% vs. 13.9%, OR: 5.51 [95% CI: 1.72-17.64]). There was no significant difference in urodynamic parameters including maximal capacity, urethral closure pressure, maximal flow rate, mean flow rate, post void residual except detrusor pressure at maximal flow rate (Pdet at Qmax), (13±8 vs. 23±15, per 10 cm H 2 0, OR 0.54 [95% CI: 0.31-0.95]). In the multiple logistic regression model, only Pdet at Qmax OR 0.94 (95% CI: 0.89-0.99) remained statistically significant. Conclusion Women with lower Pdet at Qmax are more likely to have VD after ASC. Keywords: Pelvic organ prolapse, Abdominal sacrocolpopexy, Voiding dysfunction, Urodynamics 골반장기탈출증은골반강내장기를지지하는조직의손상에의해생식기관, 방광, 직장및일부소화기관등의골반내내용물들이질벽의결손부위로탈출한상태를말한다. 우리나라에서는고령화와더불어생활수준의향상으로골반장기탈출증에대한의료적수요가증가하고있는추세이다. 최근보고에의하면자궁이있는고령여성에서자궁탈출 (uterine prolapse) 유병률은 14.2%, 자궁절제술을시행했던여성에서질구개탈출 (posthysterectomy vault prolapse) 이발생하는경우, 생식기관탈출로수술한경우가 11.6%, 그외다른양성질환으로수술한경우 1.8% 인것으로보고되고있다 [1,2]. 자궁탈출의가장표준적인수술적치료법은자궁절제술및질단부현 Received: 2010.12. 1. Accepted: 2011. 1.31. Corresponding author: Sang Wook Bai, MD Department of Obstetrics and Gynecology, Yonsei University College of Medicine, 134 Haengdang-dong, Seodaemun-gu, Seoul 120-752, Korea Tel: +82-2-2228-2241 Fax: +82-2-313-8357 E-mail: swbai@yuhs.ac 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. Copyright 2011. Korean Society of Obstetrics and Gynecology WWW.KJOG.ORG 93
KJOG Vol. 54, No. 2, 2011 수법 (suspension) 으로여러가지수술법이소개되었으나그중 1962년 Lane에의해제안된복식천골질고정술 (abdominal sacrocolpopexy) 이현재까지는가장성공률이높고재발률이낮은우수한수술방법으로알려져있다 [3]. 복식천골질고정술을포함한골반장기탈출증수술이후수술과직접관련하여발생하는합병증중가장흔한것은배뇨장애 (voiding dysfunction) 이다 [4-6]. 대부분의배뇨장애는단기간발생후호전되나 [5,7,8] 환자입장에서는수술에대한신뢰도를감소시키고불안감을조장하는문제를일으킨다. 지금까지는도뇨관삽입기간이짧을수록수술후배뇨장애가증가하고 [4-6], 도뇨관삽입기간이길수록요로감염발생이증가하며 [4-6], 재원기간이길어지는것으로보고되어왔다 [5]. 현재까지요실금수술과관련하여발생하는배뇨장애에관한연구는활발히진행되어왔으나골반장기탈출증수술이후발생하는배뇨장애에대한연구는매우적고복식천골질고정술후발생하는경우에대한연구는전혀없는상태이다. 따라서본연구에서는골반장기탈출증으로복식천골질고정술을받은환자들에게서발생할수있는배뇨장애를수술전에미리예측할수있게해주는요소에대해알아보고자하였다. 2007년 1월부터 2009년 12월까지본원산부인과에서골반장기탈출증으로복식천골질고정술을시행받은환자중기록분석이가능한 89 명의환자를대상으로후향적으로분석하였으며, 본원의임상연구윤리위원회의승인을받았다. 모든환자들은수술전에표준화된비뇨부인과문진, 이학적검사및요역동학검사를시행받았으며, 문진시나이, 산과력, 신체질량지수, 기저질환 ( 고혈압, 당뇨, 파킨슨병, 디스크질환유무 ), 폐경및대체호르몬요법시행여부, 이전자궁절제술과거력, 이전요실금수술과거력, 비뇨기계증상에대해조사하였다. 골반장기탈출증은환자를쇄석위자세로취하게하여발살바법 (Valsalva maneuver) 으로복압을증가시켜환자가평소경험하였던가장심한골반탈출을유도한후, 국제요자제학회 (International Continence Society) 의표준화된골반장기평가체계인 pelvic organ prolapse quantification system (POP-Q system) 에의거하여병기를정하였다. 요역동학검사 (Dantec-5000, Cophenhagen, Denmark) 는요류측정 (uroflowmetry), 다면적방광내압측정 (multichannel cystometry), 요도내압측정 (measurement of Valsalva leak point pressure profilometry) 를포함하며모든진찰및수술은동일인이시행하였다. 수술은복식천골질고정술과후질벽협축술 (posterior colporrhaphy) 을항상함께시행하였으며, 동시에복식자궁절제술 (total abdominal hysterectomy) 이나폐쇄공테입술 (transobturator tape) 을함께시행한경우도포함시켰다. 골반복원수술중배뇨장애에영향을줄수있는그외다른수술을함께시행한환자는연구대상에서제외하였다. 수술실에서수술직전에삽입한도뇨관은수술후 3일이나 4일째에제거하였고, 수술후배뇨장애는배뇨후 150 ml 이상의요저류가 (postvoid residual) 관찰되는경우로정의하였다. 복식천골질고정술후배뇨장애를유발하는위험인자를확인하기위해각환자들의특성, 동시수술종류, 수술시간, 이학적검사결과, 요역동학검사결과, 수술후도뇨관제거일을조사하여비교분석하였다. 통계학적결과분석은 SPSS ver. 16.0 (SPSS Inc., Chicago, IL, USA) 을사용한 chi square test, Student t-test, multivariable logistic regression analysis를시행하였고, P값이 0.05 미만인경우를통계학적으로유의하다고판정하였다. 복식천골질고정술을받은총 89명의환자중 17명 (19.1%) 에서수술후배뇨장애가발생하였고 72명 (80.9%) 은배뇨에특별한문제가없었다. 배뇨장애가있었던환자들은도뇨관을재삽입하였고, 48시간후제거하여배뇨상태를재확인하는보존적치료후약 2일에서 4일이내에모두정상적으로회복되어퇴원하였다. 동시수술로자궁절제술을같이시행한환자는 63명 (70.8%), 폐쇄공테이프술을함께받은환자는 49명 (55.1%) 으로본연구에참가한환자들의임상적특성및여러예측인자를배뇨장애가발생한군과발생하지않은환자군으로구분하여정리하였다 (Table 1). 수술후배뇨장애가발생한군과발생하지않은군간의나이, 산과력, 체질량지수, 이전수술과거력, 자궁절제술동시시행여부, 폐쇄공테이프술동시시행여부, 골반장기탈출위치, POP-Q stage, 수술전있었던배뇨장애증상, 수술시간에대한차이는통계학적으로유의한상관관계가없었다. 유의한차이를보인요소로, 당뇨병은배뇨장애환자들사이에서 29.4% 로배뇨장애가없는환자군의 12.5% 에비해유의하게많았다 (P=0.042). 수술실에서수술직전삽입한도뇨관은환자의상태에따라수술후 3일째나 4일째에제거하였고배뇨장애는수술후 4 일에도뇨관을제거한경우가 3일에제거한경우보다더많이발생하였다 (P=0.004). 수술전에시행한요역동학검사에서는최고요속시배뇨압 (detrusor pressure at maximal flow rate, Pdet at Qmax) 만이배뇨장애발생군에서 13.0±8.1 (cm H 2 O), 배뇨장애가발생하지않은군에서 23.3±15.7 (cm H 2 O) 로유의한차이 (P=0.001) 를보였고 10 cm H 2 0 단위로구분하였을때에도통계적으로유의하였다 (P=0.033). 그외 maximal capacity, urethral closure pressure, maximal flow rate, mean flow rate, post void residual에서는유의한차이가없었다 (Table 2). 다중회귀분석을통해 Pdet at Qmax만이유일하게통계학적으로유의한차이를보였고 (odds ratio [OR]: 0.94; 95% confidence interval [CI]: 0.89-0.99, P=0.046), 복식천골질고정술후발생하는배뇨장애의예측인자로 Pdet at Qmax가낮을수록배뇨장애가더많이발생하는것으로밝혀졌다 (Table 3). 94 WWW.KJOG.ORG
Su Yeon Park, et al. Predicting risk factors of postoperative voiding dysfunction after abdominal sacrocolpopexy Table 1. Demographic, surgical and preoperative characteristics VD (n=17) None VD (n=72) OR (95% CI) P value Age (yr) 59.9±12.8 62.6±8.0 0.399 Parity 3.2±1.2 3.3±1.4 0.760 Obesity (BMI 25) 7 (41.2) 21 (29.2) 0.341 Past history HTN 9 (52.9) 36 (50.0) 0.827 DM 5 (29.4) 7 (12.5) 3.87 (1.05-14.23) 0.042 Parkinson s ds. 0 1 (1.4) 1.000 Disc ds. 1 (5.9) 6 (8.3) 1.000 POP-Q stage 4 16 (94.1) 49 (68.1) 0.057 Uterine prolapse 15 (88.2) 52 (72.2) 0.221 Cystocele 2 (11.8) 20 (27.8) 0.184 Preop. Urinary Sx. Frequency 8 (47.1) 51 (70.8) 0.062 Urgency 8 (47.1) 41 (56.9) 0.461 Nocturia 4 (23.5) 24 (33.3) 0.434 Postvoid fullness 2 (11.8) 12 (16.7) 0.619 Operation time (min) 210.0±50.8 191.4±33.8 0.069 Concomitant op TAH 12 (70.6) 51 (70.8) 0.984 TOT 9 (52.9) 40 (55.6) 0.846 Foley removal 0.004 POD #3 9 (52.9) 62 (86.1) 1.00 (reference) POD #4 8 (41.7) 10 (13.9) 5.51 (1.72-17.64) Data presented as n (%) or mean±standard deviation (SD). VD, voding dysfunction; OR, odds ratio; CI, confi dence interval; BMI, body mass index; HTN, hypertension; DM, diabetes mellitus; ds, disease; Preop, preoperative; Sx, symptom; TAH, total abdominal hysterectomy; TOT, transobturator tape; POD, postoperative day. Table 2. Preoperative urodynamics and urofl owmetry parameters VD (n=17) None VD (n=72) OR (95% CI) P-value MCC (ml) 419.5±78.0 407.6±91.5 0.753 MUCP (cm H 2 0) 41.2±16.0 50.3±19.0 0.089 Max fl ow rate (ml/sec) 24.7±8.6 23.8±9.1 0.741 Mean fl ow rate (ml/sec) 11.2±3.6 11.4±4.8 0.839 PVR (ml) 37.5±45.0 46.5±63.3 0.607 Pdet at Qmax (cm H 2 0) (per 10 cm H 2 0) 13.0±8.1 23.3±15.7 0.54 (0.31-0.95) Data presented as mean±standard deviation (SD). VD, voding dysfunction; OR, odds ratio; CI, confi dence interval; MCC, maximum cystometric capacity; MUCP, maximum urethral closure pressure; PVR, postvoid residual; Pdet at Qmax, detrusor pressure at maximal fl ow rate. 0.001 0.033 고령화와더불어삶의질이향상되고여성의활동영역이증가하면서그동안간과되었던골반장기탈출증증상에대한환자들의인식이향상되었고, 부인과를찾는골반장기탈출증환자가증가하게되었다. 현재 골반장기탈출증은현대부인과영역에서주요부분을차지하며미국에서는매년약 400,000건의수술이골반장기탈출증치료를위해서행해지고, 주요부인과수술의 60% 를차지한다 [9]. 의료적수요증가와함께여러치료법또한발전하여임상적치료에서성공률이높고합병증이적은여러수술방법이소개되어왔다. WWW.KJOG.ORG 95
KJOG Vol. 54, No. 2, 2011 Table 3. Multivariable logistic regression model for risk factors of postoperative voiding dysfunction OR (95% CI) P-value P det at Q max (per 10 m H 2 0) 0.94 (0.89 0.99) 0.046 DM 2.72 (0.61 12.15) 0.190 Foley catheter remove on POD #4 3.01 (0.81 11.20) 0.100 OR, odds ratio; CI, confi dence interval; DM, diabetes mellitus; POD, postoperative day. 그중복식천골질고정술은이식재 (graft material) 를사용하여전, 후질단을천골 (sacrum) 의전종인대 (anterior longitudinal ligament) 에고정하는방법으로다른수술방법에비해우수한치료성적을보이며, Higgs 등 [10] 은 93명의질단부탈출환자를대상으로이수술을시행하여 2년간성공률 90% 이상, 재발률 3% 정도로보고하였다. 또한 Jeon 등 [11] 이복식천골질고정술을시행한 57명환자에서수술후 5년이상장기간에걸쳐조사한결과, 수술후재발을 POP-Q stage 2 이상으로정의한경우, 해부학적치료성공률은질첨부탈출 (apical prolapse) 에서는 100%, 골반장기탈출증전체에서는 86.0% 라고보고하였다. 이처럼복식천골질고정술은그효과가입증된치료법으로여러기관에서활발히시행되고있으나, 수술후발생하는배뇨장애문제가환자들의수술만족도에큰영향을주고있다. 골반장기탈출증의치료가복식천골질고정술의가장중요한목적이지만수술후합병증으로배뇨기능에이상이발생하는경우, 환자는수술성공여부에의심을품게되어이로인해불안감이조장되고재원기간이길어지거나도뇨관삽입에의한요로감염가능성이증가한다. 본연구에서는총 89명중 17명 (19.1%) 에서수술후배뇨장애가발생하였고, 이러한배뇨장애의예측인자에대해알아보고자수술전에시행한표준화된비뇨부인과문진, 이학적검사, 요역동학검사를토대로여러인자에대해후향적으로연구를시행하였으며다중회귀분석을통해 Pdet at Qmax만이유일하게통계학적으로유의한차이를보이는것을확인하였다. 배뇨근압력 (detrusor pressure, Pdet) 은방광내압 (intravesical pressure, Pves) 에서복압 (intra-abdominal pressure, Pabd) 을제한값으로 (Pves-Pabd), 배뇨작용시배뇨근 (detrusor muscle) 만의실질적인압력을의미하며, Pdet at Qmax는최대요속 (maximum flow rate) 일때의배뇨근압력을나타낸다. 본연구에서는수술전시행한요역동학검사상 Pdet at Qmax가낮을수록복식천골질고정술후배뇨장애가더많이발생하는것으로밝혀졌다. Hakvoort 등 [12] 이 345명의골반장기탈출증환자를대상으로복원수술을시행하여 cystocele이클수록, 수술중출혈이많을수록, levator placation, Kelly plication을시행한경우에서수술후배뇨장애가증가함을보고하였다. 이중수술중대량출혈은 detrusor muscle 의 innervation에광범위한손상을유발하고수술후배뇨장애에영향을미친다는보고와본연구결과는일맥상통한다. 수술전부터 Pdet at Qmax 수치가낮았던환자에게수술중출혈로인해 detrusor muscle 의 innervation에추가적인손상이발생하여배뇨장애가더많이발생할수있는것이다. 반면 Basu와 Duckett [13] 는 40명의과활동성방 광 (overactive bladder, OAB) 및배뇨근과활동성 (detrusor overactivity) 이있는전질벽탈출증환자에서 prolapse repair 전후에요역동학검사를시행한결과, 수술후 OAB가호전된환자군에서최고요속 (maximum flow rate, Qmax) 이유의하게증가하였으나 Pdet at Qmax는차이를보이지않음을보고하였다. 이는 detrusor muscle의 activity는수술전후에큰변화가없으며, bladder outflow opening의해부학적위치이상으로배뇨장애가발생하였음을의미한다. 따라서수술전 Pdet at Qmax가낮았던환자에서복식천골질고정술후배뇨장애가어떠한기전으로발생하는가에대한추가적인연구가필요하다. 본연구에서 TOT를동시에시행한환자는 49명으로이중 9명 (52.9%) 에서배뇨장애가발생하였으나이는통계적으로유의하지않았다. 그러나요실금수술후발생하는배뇨장애문제에관해서는현재까지많은연구가진행된상태로, 배뇨근의적절한수축없이발살바법으로복압을증가시켜야배뇨가가능했던환자들에게수술후배뇨장애발생이증가한다는보고가수차례발표되어왔다 [14,15]. Vervest 등 [16] 은수술전배뇨곤란이있었거나골반장기탈출증수술을동시수술로시행한경우, tension-free vaginal tape (TVT) 시행후배뇨장애발생이증가한다고발표하였고, Duckett 등 [17] 은수술전배뇨근수축외의다른방법을추가하여야배뇨가가능했던환자, 수술전 pressure flow rate <15 ml/sec인환자, 전신마취를한환자에게서 TVT 수술후배뇨장애가증가한다고보고하였다. 이는수술전부터배뇨근의기능에문제가있던환자들에게배뇨장애가발생하였다는점에서본연구결과에의미하는바가크다. 도뇨관제거일에관한연구로, Kamilya 등 [18] 이질탈출증 (vaginal prolapse) 으로수술예정인 200명의환자들을임의로두군으로나누어한군에서는수술후 1일에도뇨관을제거하고다른군에서는수술후 4일에제거한결과, 일찍제거한경우가도뇨관재삽입의위험이증가하기는하지만요로감염과재원기간을줄여전반적으로이점이더많다고발표하였다. 반면 Huang 등 [19] 은 anterior colporrhaphy를포함한 prolapse surgery 시행예정인 90명의환자를임의로세군으로나누어각각수술후 2일, 3일, 4일에도뇨관제거하였을때, subjective urine frequency, overflow incontinence, objective urine retention에대해각군간에통계학적으로유의한차이가없어도뇨관유치일은수술후 2 일을초과할필요가없다고발표하였다. 본연구에서는, 수술후환자의전반적인전신상태를고려하여수술후 3일이나 4일째에도뇨관을제거하였고, 수술후 3일에제거한경우가오히려 4일째제거에비해배뇨장애가적게발생하였다. 다중회귀분석상에서통계적으로유의한의미를나타내지못했지만, 도뇨관을일찍제거하는것이더높은배뇨성 96 WWW.KJOG.ORG
Su Yeon Park, et al. Predicting risk factors of postoperative voiding dysfunction after abdominal sacrocolpopexy 공률을보였다는점에서그원인을확인하기위해환자의수술후전신상태를고려한체계화된추가연구가필요할것으로생각된다. 당뇨병유무또한독립적인위험요인으로작용하지않는것으로밝혀졌으나 Daneshgari 등 [20] 의연구에의하면당뇨병환자에서방광의 detrusor smooth muscle과 nerve innervation 변성이발견되었고, 이는당뇨성방광기능장애 (diabetic bladder dysfunction) 의기전중일부분으로작용할것이라고발표한바있다. 현재까지우리나라에서골반장기탈출증환자의수술적치료로복식천골질고정술을시행한후발생하는합병증중배뇨장애에대해발표된연구는전혀없는상태였다. 본연구에서는특히요역동학검사결과를포함한여러가지위험인자에대해조사하였고그중, Pdet at Qmax만이유일하게연관성이있음을밝혀냈다. 그러나향후, 대규모환자군을대상으로장기간의추적관찰을통한전향적인연구및그기전에대한조사가필요할것으로생각된다. References 1. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186:1160-6. 2. Marchionni M, Bracco GL, Checcucci V, Carabaneanu A, Coccia EM, Mecacci F, et al. True incidence of vaginal vault prolapse. Thirteen years of experience. J Reprod Med 1999;44:679-84. 3. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G, Weber AM, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol 2004;104:805-23. 4. Alonzo-Sosa JE, Flores-Contreras JT, Paredes-Canul M. Method for transurethral catheterization for 1-3 days for pelvic fl oor relaxation in the postoperative period. Ginecol Obstet Mex 1997;65:455-7. 5. Hakvoort RA, Elberink R, Vollebregt A, Ploeg T, Emanuel MH. How long should urinary bladder catheterisation be continued after vaginal prolapse surgery? A randomised controlled trial comparing short term versus long term catheterisation after vaginal prolapse surgery. BJOG 2004;111:828-30. 6. Shiotz HA. Comparison of 1 and 3 days transurethral Foley catheterization after vaginal plastic surgery. Int Urogynecol J 1995;6:158-61. 7. Beck RP, McCormick S, Nordstrom L. A 25-year experience with 519 anterior colporrhaphy procedures. Obstet Gynecol 1991;78:1011-8. 8. Sokol AI, Jelovsek JE, Walters MD, Paraiso MF, Barber MD. Incidence and predictors of prolonged urinary retention after TVT with and without concurrent prolapse surgery. Am J Obstet Gynecol 2005;192:1537-43. 9. Thompson JD. Surgical correction of defects in pelvic supports: pelvic organ prolapse. In: Rock JA, Thompson JD, editors. Te Linde s operative gynecology. 8th ed. Philadelphia (PA): Lippincott-Raverpublishers; 1997. p.961-79. 10. Higgs P, Goh J, Krause H, Sloane K, Carey M. Abdominal sacral colpopexy: an independent prospective long-term follow-up study. Aust N Z J Obstet Gynaecol 2005;45:430-4. 11. Jeon MJ, Moon YJ, Jung HJ, Lim KJ, Yang HI, Kim SK, et al. A long-term treatment outcome of abdominal sacrocolpopexy. Yonsei Med J 2009;50:807-13. 12. Hakvoort RA, Dijkgraaf MG, Burger MP, Emanuel MH, Roovers JP. Predicting short-term urinary retention after vaginal prolapse surgery. Neurourol Urodyn 2009;28:225-8. 13. Basu M, Duckett J. Effect of prolapse repair on voiding and the relationship to overactive bladder and detrusor overactivity. Int Urogynecol J Pelvic Floor Dysfunct 2009 Feb 12 [Epub]. DOI:10.1007/s00192-009-0807-z. 14. Bhatia NN, Bergman A. Use of preoperative urofl owmetry and simultaneous urethrocystometry for predicting risk of prolonged postoperative bladder drainage. Urology 1986;28:440-5. 15. Sze EH, Miklos JR, Karram MM. Voiding after Burch colposuspension and effects of concomitant pelvic surgery: correlation with preoperative voiding mechanism. Obstet Gynecol 1996;88:564-7. 16. Vervest HA, Bisseling TM, Heintz AP, Schraffordt Koops SE. The prevalence of voiding diffi culty after TVT, its impact on quality of life, and related risk factors. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:173-82. 17. Duckett JR, Patil A, Papanikolaou NS. Predicting early voiding dysfunction after tension-free vaginal tape. J Obstet Gynaecol 2008;28:89-92. 18. Kamilya G, Seal SL, Mukherji J, Bhattacharyya SK, Hazra A. A randomized controlled trial comparing short versus long-term catheterization after uncomplicated vaginal prolapse surgery. J Obstet Gynaecol Res 2010;36:154-8. 19. Huang CC, Ou CS, Yeh GP, Der Tsai H, Sun MJ. Optimal duration of urinary catheterization after anterior colporrhaphy. Int Urogynecol J Pelvic Floor Dysfunct 2010 Nov 11 [Epub]. DOI: 10.1007/s00192-010-1309-8. 20. Daneshgari F, Liu G, Birder L, Hanna-Mitchell AT, Chacko S. Diabetic bladder dysfunction: current translational knowledge. J Urol 2009;182:S18-26. WWW.KJOG.ORG 97
KJOG Vol. 54, No. 2, 2011 골반장기탈출증환자의복식천골질고정술수술후발생하는배뇨장애예측인자 연세대학교의과대학산부인과교실박수연, 권하얀, 박정화, 문여정, 김세광, 배상욱 목적본연구는골반장기탈출증의수술적치료인복식천골질고정술 (abdominal sacrocolpopexy) 수술후발생하는배뇨장애 (voiding dysfunction) 를예측할수있는인자를알아보고자한다. 연구방법 2007년 1월부터 2009년 12월까지본원산부인과에서골반장기탈출증으로복식천골질고정술을시행받은총 89명의환자를대상으로후향적연구를시행하였다. 환자들의 POP-Q system에따른병기를포함한임상적특징, 산과력, 수술력, 수술후도뇨관제거일을조사하였으며, 수술전시행한요역동학검사들의결과를검토하였다. 수술후배뇨장애가발생한환자들을조사하여배뇨장애가발생하지않은환자들과비교분석하였다. SPSS 프로그램을이용하여분석하였으며, χ 2 test와 t-test를이용하여두군의차이를비교하였고다중회귀분석을이용하여수술후배뇨장애의발생에영향을미치는요인들을알아보았다. 결과복식천골질고정술을받은 89명중 17명 (19.1%) 이배뇨장애를호소하였다. 배뇨장애가발생한환자군과발생하지않은환자군의임상적특징중당뇨가있거나 (29.4% vs. 9.7%, odds rations [OR]: 3.87, 95% confidence intervals [CI]: 1.05-14.23), 도뇨관제거일이늦은경우 ( 수술후 4일 : 47.1% vs. 13.9%, OR 5.51, 95% CI 1.72-17.64) 유의한차이를보였고요역동학검사결과비교에서는 detrusor pressure at maximal flow rate (Pdet at Qmax) 가 (13±8 vs. 23±15, per 10 cm H 2 0, OR 0.54, 95% CI 0.31-0.95) 유의한차이를보였다. 다중회귀분석을통해이들중 Pdet at Qmax (OR 0.94, 95% CI 0.89-0.99) 만이통계적으로유의한차이를보였다. 결론골반장기탈출증치료로복식천골질고정술을시행하는경우, 수술전시행한요역동학검사상 Pdet at Qmax가낮을수록수술후배뇨장애가발생할가능성이증가한다. 중심단어 : 골반장기탈출증, 복식천골질고정술, 배뇨장애, 요역동학검사 98 WWW.KJOG.ORG