- 吳周炯外 : 賢 f 員傷의超音波檢흉및 電算化斷層提影所見上比較分析 - tomographic staging of renal trauma; 85 consecu- 사선학석 고찰 대한땅사션의학회지 17: 115-1, tive cases. ] Urol 136:561-565, 1986 1981 7. Sanders RC: The place of diagnostic ultrasound in 15. Cass AS, Luxenberg M: Conservative or immediate the examination of kidneys not seen on excretory surgical management of blunt renal injuries. ] Urol urography ] Urol 114.813-81, 1975 130:11-16, 198 8. Kay CJ, Rosenfield AT, Armm M: Gray- scale ultra- 16. Karp MP, J ewett TC, Kuhm JP: The impact of sonography in the evaluation of ren al trauma. computed tomography scanning on the child with Radiology 134:461-466, 1980 renal trauma. ] Pediatr Surg 1 :6 1 까63, 1986 9. Schmoller H, Kunit G, Frick J: Sonography in blunt 17. Lang EK. Sullivan J, Frentz G: Renal trauma, renal trauma. Eur Urol 7:11-15, 1981 radiological studies comparison of urography com - 10 강정자, 정해양, 조온구동 : 신외상의방사선학석 puted tomography, angiography and radionuclide 고찰. 대한방사션의학회지 19 : 4-41, 1981 studies. Radiology 154:1-6, 1985 11. J akse G, Furtschegger A, Egender G: Ultrasound in 18. Well FS, Bihr E, Rohmer P: Renal sonography patients with blunt renal trauma managed by nd Ed 147-05, 1987 surgeryj Urol 138:1-3, 1986 19. Kaplan GN, Sanders RC: B-scan ultrasound in the 1. Cass AS, Ireland GW: Comparison of the conserva- management of patients with occult abdominal tive and surgical management of th e more severe hematomas. ] Clin UJtrasound 1-5, 1973 degrees of renal trauma in multiple injured patients. 0. Taylor KJW, Viscomi GN: Ultrasound in emergen - ] Urol 109:8-10, 1973 cy medicine. 33-54, 1981 13. Thompson 1M: Expected management of blunt renal 1. Resnick M1, Sanders RC: Ultrasound in urology trauma. Urol Clin North Am 4:9-3, 1977 178, 1979 14 이혜경, 정인태, 최득렌둥 : 신손상의임상적및방 - 1017 -
박만수외. 싱성! 융동한정껴 l 정끽듀의징피석색선술 설치하였마. 그러고 6. 5F의 cobra heað 카테타를이 용하여신정맥을선택하여 76 % urograffin 3 0 cc를초 당 15 cc씩 주입하연서 조영숭을시행하였다. 신정맥조영술은내정계정액의수와경로를정확하 게 판단하여 색전술에대한선체적인계획을세우기 위해시행하였마. 그후 6.5F의 head hunter 카테타를사용하여내정 계정액내로갚숙히카테타를밀어넣고선택석내정계 정맥조영술을시행하였다. 내정계정액죠영술의결과에짜라각환자의알맞은 폐쇄부위까지카터1 타를삽입시컨후코일을 straight guide w ir e를이용하여카테타내부로밀어넣은후 X -선투시하에서 코일을 내정계정액내로 진입시켰 다. 색선에사용된코일의숫자는내정계정액의수와모 양에따라결정하였다. 색천에사용된코일은신정액 이냐하대정액 A로의이달을악기위해내정계정액의 직경보다큰직경의코일을사용하였는데주로 3, 5, 8 mm ( Cook제품 ) 의코알이사용되었고내정계정액의폐쇄후내정계정액내에생긴혈전이이탈하여페색선을야기하는것을막기위해폐쇄에사용된코일중에서적어도하나는가급적신정액의근위부위에서사용 하였다. 우측의경우도같은방법으로시행하였다. 색전울시행후 1 5-0분후다시신정액조영술을시챙하여폐쇄여부와측부순환유무를확인하였마. Ill. 결과전례에서좌측내정계정액을선택하는데큰어려웅이없었고그중 1 례에서는큰어려웅이없었고그중 1 례에서는우측내정계정액을어려웅없이쉽게선택할수있었마. 정맥조영술결과내정계정액의직경은 -6mm 였고좌신정액과내정계정액이 1 루는각도는전례에서 90 를보여주었고내정계정액의수는 -5개로전례에서판악부전으로인한조영제의내정계정맥내로의역류현상을판찰할수있었마 ( Tabl e 1). 6 례에서는정맥조영술의결파에짜라원하는위치에서코일로내정계정맥의폐쇄를시행할수있었 A나 1 례에서는내정계정액의숫자가않고정액의직경이가늘고경로의굴곡이심해카터 1 타의정액내로의신엽이어려워색전술을시행할수없었마 ( Fig.4 ). 시울시흔한나타냐는정맥경축현상무로인한시술 a b F ig. 1. <1. Left renal venogram shows two opacified left internal sperm atic veins b. Selective left internal spe rm atic venogram shows left internal sperm ati c vei n and coll ateral channels. c. In ve nog ram performed foll owi ng placement of two coil s at L-3 and S 1. level(3,5mm ), intern al spermatic vein and coll ateral channels are visualized Extravasated contrast media is noted due 10 rupture of ISV.1 SV: in tern al spermatic vein - 1019 -
- 大韓放射線뿔學용註 : 第 5 卷 第 6 號 1989 a b C Fig.. a. Left renal venogram shows straight course of ISV (b). Venogram taken after deep catheterization into ISV shows small collateral venous channel which drained int 이 stal ISV (c). Final venogram shows occlusion of the ISV and collateral following placement of 5mm coil at L-3 level Table 1. Results of Internal Spermatic Venography 의 case 1 3 4 5 6 7 No of veln 3 4 3 RT;3 LT; angle grade nu mωnu mωmωmωm 어려움은없었으나 1 례에서는내정계정액의파옐 로안한조영제의정액외유출이있었마 (Fig. l(c)). 시술후 1 례에서는원인불명의 39 0 c 의고열이있었 으냐항생제투여로곧완화되었마. 색천후 1 5-0 분후시술의성공여부를확인키위해 시행한신조영술에서는폐쇄펀이하부위로의조영제 의역류현상은판찰되지않았우며정액의경축으로인 한코일의이탈도없었다. emboli zat lon no RT; LT; cali ber of"'isv 5mm, mm 4mm, 4mm 6mm, mm 6,,5mm 6,3,mm 5,3,mm 5mm, 4mm, angle: internal spermatic.left renal confluence, graded by Mali '" ISV: internal spermatic vein 6 례에서시술후 년간추석검사결과전례에서재말 이없이음낭동통파음낭종물이없어지는결파를얻을수있었다. 환자의전례에서시술후정액검사가시행되지못해시술과정자형성의호천여부판계는조사되지뭇하였다. N. 고잘 정계정액류는활동력이왕성하고음낭내혈류가크게증가하는 15-5세연령에서발생하는남성불임의가장않은원안으로알려져왔마 1. 7.8 ) 대부분좌측에서발생하며좌측에호말하는원인은첫째, 우측의내정계정액은하대정액과비교적급격한경사를이루변서유입되는데비하여좌측은신정액파직각을이루연서유입되기해문이며둘째, 좌측신정액은대동맥파상장깐동액사이에서압박을받거나또는 treitz ligament에의해압박을받는다 1.9 ) 불임증을유발하는원인은확살치않A나최근까지보고된운헌을종합해보면 (1 ) 음낭내혈액의정체로인한온도조절기전의실조 10 ) () 신장이냐부신에서만들어진스테로이드나 cathech o lamine같은독성물질의음낭내로의역류 11. - 100 -
박만수외 갱쟁 1객을통한정겨 1 정끽류의갱피석색선슬 (3) 좌우음낭사이에서의풍부한운합 7) (4 ) 음낭내혈류강소로인한 anoxla 상태등이보고되고있다 13 ) 정계정액류의치료업에는수술석요법파정파석색전술의두가지방엽이있는데수술적요업은 Tulloch 가 1 95 년처음흐로내정계정액의결찰로정계정액류가소설되고정자형성이회복되는것을보고한이래정계정액류의결찰술이이용되고있다. 그러나수술적요엽이선신마취와입원을필요로하고전체석안내정계정액의해부학적쿠조와측부순환을확인하지않고시행할경우재알의위험성이있으며또한수술시내정계동액의손상을초래할가능성이있는단점이있마. 경피석색전술은 1978 년 Lima둥이대퇴정액을통하여 sclerosing agent와 g lucose so lut i o n을혼합하여내정계정액의폐쇄를시도한이래로새로운치료엽으로사용되고있다. 정펴석색선술은국소마취로시숭이가능하며입원할필요가없으며비용이석게들고수술후발생할수있는헬종이나음낭수종이생기지않으며정액조영술시행후정확한해부학석구조를파악한후시행하기애문에정확한위치에서정맥을폐쇄시킬수있는장점이있마. 경파석색선술은대퇴정액을이용하는방엽과경정 액을이용하는방엽이있는데흔히사용되는대회정액 을통한방법은대퇴정액에서 l-\l 정계정액에이르는정 액의경로가곧지옷하고원형을이루고있는해부학 석구조혜문에내정계정액을선택하는데어려웅이있 으며, 선택이되어도카테타를내정계정액내로갚숙 히삽입하기가어려워원하는부위에서의정액의폐쇄 가용이치않으며, 특히우측내정계정액의경우는하 대정액과급격한경시후이루고있기애문에선택에 큰어려웅이있다 14 ) 이에반하여경정액을통한방엽은경정액에서내정 계정맥에이르는혈판의경로가곧아쉽게내정계정액 을선택할수있고특히우측내정계정맥도쉽게선택 할수있는장점을가지고있다 3. 14 ) 색전물질로는흔히스프링코일, sclerosing agent, detachable ba ll oon 둥이사용되고있다. detachable ba ll oon 은정확한위치에서정액을폐쇄시킬수있고 다흔부위로의이탈가능성이적으며시술시거의통증 을유말하지않으냐값이비싼단점이있다 5) 이에비 해 scle rosing age nt 는측부순환의혈판까지폐쇄시킬 수있으나시숭시통증을유말시킬수있고내정계정 액폐쇄후재소통 ( r ecana l iza t io n ) 이얼어날수있 A 며 일단 sclerosing age n t 가주입되고나연제어할수 없는단점이있다 15. 1 6 ) 3.8 b 4. Fig. 3. a. Selective left internal spermatic venogram shows tortuous multi ple coll ateral venous channels (b). In post-embolization with coils (3, 5, 8mm) at L-3, S I and pelvic cavity, ISV and collateral channels are not visualized. Fig. 4. Left renal venogram shows mul tiple tortuous in lern al spermati, vei n. E mbolizati on could not be performed - 101 -
大함放射線짧쩔曾註 第 5 卷第 6 號 1989 - 스프렁코일은 detachable balloon보다는폐쇄부위의정확성은약간떨어지지얀시술이용이하고값이싸며추적검사가용이한장점이있기혜문에저자는스프링코알을색선물질로사용하였마 14 ) 치료성석을살펴보연수술적요업인고결찰울시 (high ligation ) 재딸율이 5-0 % 이고 1 6 ) White등은 detachable balloon을이용하여단지 % 의재발율을보고하고 5) 있고 Seyfe rth둥은 sclerosing agent를사용하여 3% 에서만지속석안정계정액류를보여주었마고보고하고있마 15 ) 코일을사용하였을시에는 Berkman등은좌정계정맥류의경우는 100 % 우정계정액류의경우는 90 % 의성공율을보여주었고 1 7) 국내에서는양승오둥이대퇴정맥을통한색선술을시챙하여 10영중 8 영이음낭종물이소실되었다고보고하고있마 ) Morag동은 3예의환자에서경정액을통한색전술을시행하여좌측정계정액류의경우는 9 % 의성공율을보여주어대퇴정맥을통한성공률 93.5% 와유사한효과를보이나우측의경우는 89 % 와 6.5 % 로경정액을통한색진방법이우측정계정백폐쇄에특히우수하마고주장하고있다 14 ) 저자들은 7 례에서경정맥을통한색선술을시행하여 6 례에서내정계정맥을성공석으로폐쇄시킬수있었고재말이없이정계정맥류가소실되는결과를얻을수있었다. V. 결론정계정액류 7 례에서정정맥을통하여스프링코일을재료로경피적색선술을시챙하여 6 례에서내정계정맥을폐쇄시킬수있었고, 그후 년간추적검사결파재발한예는없었다. 경정맥을통한색선숭이내퇴정액을통한땅엽보마시술이용이하고코일을내정계정액내로깊숙허밀어넣을수있어시술후재말의위험성이석은얀천한땅엽이며우측내정계정액도쉽게폐쇄시킬수있는장점이있기혜운에수술석요엽을대치할수있는좋은치료법 A로사료된마. REFERENCES 1. Dubin L and Amelar RD.: Etiologic!actors in 194 consecutive cases o! male in!ertility. Fertil steril.:469 양승갑, 성희영, 나현재, 양승오 : 정계정맥류 10 례 에서코일을사용한경파적색전술. 대한비뇨기파학 회지 9 : 85, 1988 3. Augustin F. Berry R Christoph Z et al: Emboli zation o! th e spermatic vein!or treatment o! in!er tility. A new approach Radiology, 139:315,1 981 4. Lima SS. Castro MP. and Costa OF.: A new method!or treatment o! varicocele. Andrology 10:103. 1978 5. White RI Jr. Kaufman SL Klemens HB et al Occlusion o! varicocele with detachable balloons Radiology, 139:37, 1981 6. Mali WP. Oei HY. Arndt JW et al: Hemodynamics o! the varicocele. PartJ Cerrelation among the clinical, phlebographic and scintigraphic findings 1 Urology, 135:483, 1986 7. Clarke BG.: lncidence o! varicoceles in normal men and among men o! different ages. I A.M.A., 198.'111, 1966 8 이윤형. 정계정액류의통계적판찰. 대한비뇨기과 학회지 11: 13, 1970 9. Kohler FP: On th e etjology o! varicocele. 1 Urol. ogy, 97741, 1967 10. Jorgniotti AW. and MacLeod J: Studies in temper ature, human semen quality and varicocele. Fertil Steril, 4:854, 1974 11. Greenberg SH. Lipshultz L I. Wein AJ: Experience with 45 sub!ertile male patients. 1 Urol., 119:507, 1978 1. Mac Leod J: Seminal cytology in the presence o! varicocele. Fertil Steril, 16:735, 1965 13. Charny CW.: Effect o! varicocele on fertility. Fertil Steril, 13:4 7, 196 14. Morag B. Robi nsstein Z]. Go ldwasser B. and Yerushalmi A.: Percutaneus Venography and occlu sion in the management of spermatic varicoceles A.].R., 143635, 1984 15. Seyferth W. Ekkehard J and Eberhard Z.: Percu tan eo us sclerotheraphy o! varicocele. Radiology, 139.335, 1981 16. Kau fm an SL. Kadir S. Barth KH et al: Mechanism o! recurrent varicocele after balloon occlusion or surgical ligation o [ the in ternal sperm atic vein 10 -
- 박만수외 : 경정액을통한정계정끽류의경피식색선술 - Radiology, 147:435, 1983 of North America, 3:563, 1978 17. Berkman WA. Rogert BA. and ]oseph KE.: Vari -. Go nzalez R. Narayan P. and Formaneck AG coceles;a coaxial coil occlusion system. Radiology, 151.73-77,1981 18. Lewis RW. and Harrison Rm.: Diagnosis and treat ment of varicocele. Clin. Obst. Gynec., 5:501, 198 19. P eter R. Gerhard L and Walter S.: A new method of transfemoral testicular vein obliteration for varicocele usmg a balloon catheter Radiology, 139.33, 1981 0. Tulloch WS.: Consideration of sterility factors in light subfertility in male. Edinbergh Medicine Journal, 59:9 1. Dubin and Amelar RD.: Varicocele. Urologic clinics Transvenous emoolization of internal spermatic vein. Radiology, 141.,57 3. Kiszka EF. and Cowart EF. and Cowart GT Treatment of varicocele by high ligation. I Urol., 83:713, 1960 4. 우자현 : 정계정맥류술중내정계정액촬영슐에관한 임상석연쿠. 대한바뇨기과학회지 3 : 967, 198. 5. 김영우 : 정계정액류에판한임상적판찰대한비뇨 기과학회지 3 : 973, 198 6. 김준현 : 정계정맥류 36 례에대한임상적판찰. 대한 비뇨기파학회지 3 : 550, 198 7. 김희경 : 정계정액류의정액조영상에판한임상적판 찰. 대한바뇨기파학회지 : 435, 1981-103