소아신손상의치료 : 보존적치료접근법 Treatment in Pediatric Renal Trauma: A Conservative Management Approach Young Ho In, Ji Hyeong Yu, Luck Hee Sung, Choong Hee Noh, Jae Yong Chung From the Department of Urology, College of Medicine, Inje University, Seoul, Korea Purpose: The management of pediatric trauma is substantially derived from the results of adult trauma patient. Despite the increasing of pediatric renal trauma, the management of them still remains controversial. The aim of this study is to evaluate our experience with the expectant conservative management of blunt trauma in children. Materials and Methods: We retrospectively studied 45 pediatric patients with renal trauma between 1995 and 2007. We reviewed medical records for clinical symptoms, mechanism of injury, assigned grade of renal injury, associated injuries, indication of surgery, and treatment outcomes. We graded renal injuries according to the American Association for the Surgery of Trauma Organ Injury Scale. Results: All patients of grade I, II, III, and IV were managed conservatively at beginning, if the hemodynamic state is stable. Among them, 2 patients of grade IV were done delayed operation. One patient underwent delayed renorrhaphy for persistent anemia and hypotension, and the other patient needed delayed nephrectomy because of persistent fever and worsening abdominal pain with significant urinary extravasation. All patients of grade V were undergone early nephrectomy. Conclusions: Except for persistent fever with significant extravasation and grade Ⅴ injury, initial conservative management of blunt renal trauma in children is effective and recommendable at beginning, if the hemodynamic state is stable. Prospective larger randomized controlled trials will be needed. (Korean J Urol 2009;50:1125-1132) Key Words: Pediatrics, Kidney, Injuries, Treatment outcome Korean Journal of Urology Vol. 50 No. 11: 1125-1132, November 2009 DOI: 10.4111/kju.2009.50.11.1125 인제대학교의과대학비뇨기과학교실 인영호ㆍ유지형ㆍ성락희노충희ㆍ정재용 Received:June 8, 2009 Accepted:October 12, 2009 Correspondence to: Jae Yong Chung Department of Urology, Sanggye Paik Hospital, Inje University, 761-1, Sanggye-dong, Nowon-gu, Seoul 139-707, Korea TEL: 02-950-1137 FAX: 02-933-6133 E-mail: chungj90@paran.com C The Korean Urological Association, 2009 서론 2008년미국내보고에의하면, 손상은소아사망에이르게하는원인중약 59.5% 를차지하며 [1], 국내의한연구보고에서는소아의응급실내원후사망원인을보면사고에의한원인이 41.8% 로가장많았다 [2]. 이처럼소아손상에서교통사고가많은비중을차지하며, 보행자사고는 5-9 세에호발하고, 남아에서여아보다 2배더많다. 비뇨생식기손상으로사망에이르는경우는매우드물지만, 소아에서비뇨생식기계손상은중추신경계다음으로외상이잘일어나는호발부위이다 [3]. 지금까지는이러한소아신손 상의경우도성인의치료경험에기초하고있으나, 성인과다른해부학적, 생리학적특수성과선천성기형이있는경우에는더쉽게손상을받을수있는점을고려하였을때, 아직도진단방법과치료방법에서보존적치료와조기수술적치료사이에논란의여지가있어 [4], 본원에서의경험을분석하여소아신손상의보존적치료의안전성과보존적치료에실패한경우에대하여알아보고자하였다. 대상및방법 1995년 1월부터 2007년까지둔상성신손상으로본원에서치료를받은 45명의소아환자를대상으로하였으며, 의무 1125
1126 Korean Journal of Urology vol. 50, 1125-1132, November 2009 기록을후향적으로분석하였다. 환아의증상과신체검사소견으로신손상이예상되는경우, 모든경우에서조영제를이용한전산화단층촬영을이용하여진단하였으며, 신손상의정도는 American Association for the Surgery of Trauma Organ injury Scale에서제시하는 kidney injury scale을적용하였다 [5]. 손상원인, 내원당시환자의임상양상, 신체검사, 혈색소, 혈뇨, 그리고동반장기손상에관한기록을확인하였고, 입원기간중의변화를분석하였다. 둔상성신손상시보존적치료의결과및합병증을조사하였고, 조기수술이필요한경우, 보존적치료가실패하였을때지연수술이필요하였던경우그리고그결과및합병증도조사하였다. 대부분의경우에보존적치료는예방적항생제투여와함께육안적혈뇨가없어질때가지침상안정을취하도록하였고, 활력징후와요량의근접관찰, 주기적인복부신체검사와혈색소측정을시행하였다. 입원 4-5일까지는혈색소, 혈청전해질및크레아티닌을매일검사하였으며, 손상의정도가비활력분절을동반한 grade III와 grade IV 이상의경우에는손상 1-2주이후전산화단층촬영을추적검사하여초기의손상정도와비교하여확인하였다. 대부분의환아에서퇴원후신손상의회복과신기능의평가를위해혈색소수치와크레아티닌을시행하였고, 3개월째전산화단층촬영을시행하여초기의소견과비교하였다. 조기수술적치료는초기진단후 24시간이내로규정하였고, 신손상으로인한합병증을초기와지연성으로구분하여조사하였다. 결과 45명의대상환아는남아 32명, 여아 13명으로평균추적기간은 10.8±5.4개월, 평균연령은 11.0±5.2세였다. 신손상기전으로는교통사고 14명 (31.1%), 추락 11명 (24.4%) 순으로많은비율을차지하였고 (Table 1), 초기증상으로는옆구리통증이 35명 (77.7%) 으로가장많이나타났으며, 육안 적혈뇨은 27명 (60%) 에서관찰되었다 (Table 2). 20명 (44.4%) 의소아에서타장기손상이동반되었으며, 근골격계와흉부의동반손상이많았다 (Table 3). 본연구의대상환자중에는신장의신우요관이행부폐색과같은선천성기형이동반된경우는없었다. 내원당시혈류역학적으로안정한 41명은모두초기보존적치료를시행하였다. 각 grade별로 grade I, II, III, IV에해당하는환자는각각 17명 (37.7%), 7명 (15.5%), 7명 (15.5%), 10명 (22.2%) 이었다. 초기보조적치료를시작하였던환자중 39명은활력징후가안정적으로유지되고, 2주이내의전산화단층촬영의단기추적에서도손상의정도가진행되지않아보존적치료를지속할수있었다. 그러나 grade IV에해당하는 4세남아 1명 (Fig. 1) 은수혈및보존적치료에도지속적인출혈과활력징후의불안정으로손상후 3일째지연수술을시행하였으며, 괴사된부분의제거와남아있는신분절의봉합을통한신구제술을시행하였다. 또한초기요누출소견을보인 grade IV 환아 4명 (60%) 중 3명은요누출로인한일시적발열이있었으나, 보존적치료만으로호전되고, 손상후단기전산화단층촬영소견에서도요누출이소실되어요관부목이나신루설치술등의중재적시술없이도보존적치료를지속할수있었다. 그러나나머지 1명의환아는초기에보존적치료를시작하였으나복막뒤공간내요누출의증가로인한발열 Table 2. Clinical manifestation on initial assessment Clinical manifestation No. of patients (%) Flank pain 35 (77.7) Abdominal pain 5 (11.1) Gross hematuria 27 (60.0) Microscopic hematuria 34 (75.5) Nausea/Vomiting 2 (4.4) Decreased mentality (shock state) a 4 (8.8) a : defined to any score below 27 of mini-mental state examination Table 1. Characteristics and mechanism of injury Mechanism of injury Total No. of patients Male:Female Mean age Mechanism of injury Pedestrian traffic accident (%) Fall (%) Slip down (%) Others (%) No. of patients 45 32:13 11.0±5.2 14 (31.1) 11 (24.4) 10 (22.2) 10 (22.2) Table 3. Associated extrarenal injuries (n=20) Associated injuries Grade I II III IV V Total (%) Head 2 0 0 0 0 2 (4.4) Chest 1 0 0 2 1 4 (8.9) Skeletal 6 1 0 0 1 8 (17.8) Liver 1 1 0 0 1 3 (6.7) Spleen 0 0 1 1 1 3 (6.7) Bowel 0 0 0 0 0 0 (0.0) Total 10 2 1 3 4 20 (44.4)
Young Ho In, et al Conservative Management in Pediatric Renal Trauma 1127 Fig. 1. Radiographic appearance of grade IV right renal injury in a 4-year-old child whose conservative treatment was failed. (A) Computerized tomography (CT) presents deep lacerations with main vascular injury of right kidney. (B) CT shows well healed kidney after 3 months from renorrhaphy. Fig. 2. Eight-year-old child with blunt renal trauma. (A, B) On admission, computerized tomography (CT) shows perinephric extravasation of contrast media from left upper collecting system. (C) Follow-up sonography 4 weeks later presents new developed hydronephrosis and increased perinephric urinoma. (D) Diethylenetriaminepentaacetic acid (DTPA) lasix renal scan image 5 weeks after injury shows relative delay in clearance from the left kidney and demonstrates relatively decreased renal function. (E) At 7 weeks after injury, ureteral stenting was done. (F) CT shows infarction of left kidney just before nephrectomy.
1128 Korean Journal of Urology vol. 50, 1125-1132, November 2009 Table 4. Classification and management of renal injury Initial CT finding Management Delayed complication Kidney salvage rate (%) No. of patients Grade I Grade II Grade III Grade IV Grade V Contusion (10) Subcapsular hematoma (7) Perirenal hematoma (2) <1 cm laceration (5) 1 cm laceration (7) Urine extravasation (4) Main vascular injury (6) Shattered kidney (3) Hilar avulsion (1) Conservative (17) Conservative (7) Conservative (7) Conservative (8) Delayed renorrhaphy (1) Delayed nephrectomy (1) Early nephrectomy (4) 100 100 100 90 0 17 7 7 10 4 Table 5. Complication of the initial conservative treatment Complications Transfusion Hypotension due to persistent hemorrhage Transient fever Fever due to persistent urine leakage Death Total 11 (26.8%) No. of patients 6 1 (delayed renorrhaphy) 3 1 (delayed nephrectomy) 0 이지속되며, 수신증이발생하여요관부목삽입술의시술을시행하였음에도불구하고활력징후가불안정해지고, 복부통증및신경색으로인하여손상후 8주째지연신적출술을시행하였다 (Fig. 2). 결국초기보존적치료를시행하기로결정한 41명중 2명의환아에서신봉합술의신구제술과신적출술의지연수술이필요하였고, 전체적으로보았을때 40명 (97.6%) 의대부분의환자에서보존적치료의지속및지연적신구제술을통하여신장의보존이가능하였다 (Table 4). 보존적치료의초기합병증이발생한환아는 11명 (26.8%) 으로 6명 (grade III: 2명, grade IV: 4명 ) 에서수혈이필요할정도의경한출혈과, 활력징후를악화시킬정도의지속적인출혈 (grade IV: 1명 ) 및일시적인발열, 그리고요누출로인한지속적인발열 (grade IV: 1명 ) 이있었다 (Table 5). 특히 grade IV 10명중 8명 (80%) 에서초기보존적치료만으로증상이호전되고큰합병증없이퇴원가능하였다. Grade V에해당하는 4명의환아는내원당시모두불안정한활력징후와동반된타장기손상으로, 조기수술을시행하였으며, 3명은조기신적출술을시행하였고 (Fig. 3), 1명은조기신적출술을시행하였으나타장기손상으로인한혈흉과동반된패혈증으로결국사망하였다. 신손상의호전정도는 3-6개월후 grade II, III의일부환아와지연신절제술을시행한환아를제외한 grade IV의모 든환아에서전산화단층촬영을추적검사하여확인하였다. 호전의정도를정량적으로정확하게파악할수는없었지만, grade II와 III 환아에서는 4주이내대부분의혈종의크기와신실질열상이호전되는양상을보였고, grade IV의환아는혈종의감소정도가 grade II, III 손상에비해더오래지속되었지만 3개월이내대부분의혈종이흡수되고신실질열상이호전되는양상을보였다 (Fig. 4). 그러나본연구에서는요누출이지속되거나신주위농양소견을보이는경우는없었다. 본연구에서는 1년이상추적관찰이가능하였던주로 grade III 이상의 15명환아모두에서수신증, 결석형성, 고혈압, 신주위농양등의지연합병증이발생한경우는없었다. 고찰신장은복부뿐아니라비뇨생식계에서도가장호발하는손상부위이다. 대부분흉부, 척추, 골반및복강내장기손상과동반되며 [6], 특히소아의경우는성인과달리, 미숙하고약한흉강과근육, 적은신주위지방, 낮은신장의위치로인해손상의이환율이높고 [7], 손상의원인이추락사고에의한경우가많아중증신손상의빈도가높다 [8]. 본연구에서는교통사고에의한경우가 11명으로가장많았으며, 남녀비에서는본연구에서와마찬가지로남아에서빈도가높다. 그러나실제로성인보다발생률이높은지에대한논쟁의여지도있다. 신손상은대체로둔상성과관통성손상으로분류되고, 전자는소아신손상의 90% 이상의원인에해당한다 [9]. 대부분의둔상성신손상은타박상이며적극적인치료를필요로하지않고 [10,11], 관통성손상은성인보다매우드물며, 본연구의경우도모두둔상성손상에해당하였다. 소아는성인신손상환자의컴퓨터단층촬영과비교하였
Young Ho In, et al:conservative Management in Pediatric Renal Trauma 1129 Fig. 3. Computerized tomography (CT) scan showing a grade V traumatic injury of left kidney each other. (A) 14-year-old boy, (B) 6-year-girl, transverse section image showing the shattered renal parenchyma of mid pole kidney. Early nephrectomy was required in all patients. Fig. 4. The durations of improvement was longer in the higher grade injury comparing the lower grade one in follow-up images. (A, B) Parenchymal lacerations and amount of hematoma were resolved in 3 months after grade IV injury. (C, D) Perirenal hematoma was resolved completely in 4 weeks after grade III injury.
1130 Korean Journal of Urology vol. 50, 1125-1132, November 2009 을때, 전에존재하는신기형 ( 신우요관이행부협착, 수신요관증, 마제신등 ) 이 3-5배많으며, 이때중증의손상이잘발생한다는가설도제기되고있으나, Chopra 등의연구에서는신기형이동반한경우에도대부분타박상이나경도의손상에지나지않았다고하였고, 이번연구에서이러한신기형이동반된환아는없었다 [12]. 둔상성비뇨생식계손상환자의약 98% 에서육안적혹은현미경적혈뇨를보이는것으로알려져있다. 그러나소아에서는신손상을선별하는데혈뇨는매우신뢰할수없는소견이다. Morey 등에의하면, 소아에서 grade II 이상의손상임에도불구하고 70% 에서혈뇨의소견이없었으며 [13], 이는소아신손상의경우혈뇨의유무만으로방사선검사의필요성을판단해서는안됨을보고한것이며, 이번연구에서는 60.0% 에서육안적혈뇨의증상이있었다. 또한 2004 년 Santucci 등은육안적혈뇨에만의지하지않고, 혈류역학적상태, 감속성손상기전, 타장기의동반손상유무을고려하는방사선적평가의적응증을제시하기도하였는데, 소아의경우에는신손상의의심되면반드시방사선학적검사를시행할것을주장하고있다 [14]. 소아신손상의치료는크게보존적치료와조기수술적치료가있으며, 여러연구를보았을때신적출술의빈도가보존적치료시보다조기수술적치료시에더높았다 [15,16]. 이는제로타근막의탐포네이드효과가출혈을방지하는것으로생각되며, 수술적치료시제로타근막이파열되면서신적출술을필요로하는확률이높아지는것으로예상된다. 최근에는혈류역학적안정성, 방사선적정확한단계, 그리고동반된타장기손상에근거하여수술적치료를고려한다고보고하고있으나, 아직명확한치료방침에대한논쟁이있어본연구의목적과부합된다고할수있다. 신손상에의한혈류역학적불안정시, 박동성의후복막혈종의증가, 혈관경색술에도불구하고지속적인출혈시에는수술적치료의절대적적응증이되며, 방사선적검사에서손상의정도가모호한경우, 타장기손상을동반한 grade III 이상의손상시에도개복술을고려할수있다고하였다 [17,18]. 이때시험적개복술이나신봉합술의구제적수술이선호되나, 다장기손상이나구제술이불가능한경우신적출술을시행한다. 1983년 Cass와 Luxenberg는 grade IV, V의중등도손상에서초기보존적치료에실패하여신적출술을시행한경우와조기수술한경우를비교하였고, 다발성손상을동반한신손상환자의 73% 에서결국수술적치료가필요함을보고하여, 조기수술적치료가이환율, 재원일수, 고혈압등의합병증을줄인다고하였다 [19]. 최근에는 Santucci 등이비록소아에게만국한된경우는아니지만 the American Association for the Surgery of Trauma Organ Injury Severity Scale와신수술의밀접한상관관계를제시하며, grade III, IV 손상시각각 73%, 78% 에이르는높은수술률을보고하기도하였다 [20]. 본연구에서는 grade IV 손상시 20% 의수술률과 90% 의신구제율을보고하였다. 그러나소아에서는논란의여지가있지만, Husmann 등은일반적으로보존적치료의대상은손상의기전및타장기동반손상에관계없이 grade I 혹은 II에해당하는환자이며, 보존적치료시합병증도매우드물다고주장하였고, grade III, IV 혹은 V의손상에서도보존적치료를시행할수있다고하였다 [21]. 또한 Russell 등과 Rogers 등은모든소아신손상단계뿐아니라집합계파열과요누출이있는경우에도하부요관이온전한경우보존적치료의금기가될수없고, 혈관조영술및내시경적혹은경피적시술을시도할수있다고보고하였다 [22,23]. 이러한결과로 Heyns 등과그외여러연구자들은 grade III, IV에국한된손상환자에서 94% 가수술적치료를피할수있었다고보고하였고 [17,18,21,24], 국내에서는 Joung 등이초기보존적치료를시작하였던환자의 94.6% 가추가적시술없이치료의성공이가능하였다고보고하였다 [25]. 최근 Buckley와 Mc- Aninch는 327명의둔상성소아신손상의결과에서 98.2% 의보존적치료성공률을보고하였고, 이는 86.7% 에서수술적치료를요하지않았던본원의경우와도비슷한결과이다 [6]. 또한 Altman 등은 grade V에서도보존적치료의가능성을제시하기도하였다 [26]. 보존적치료시에는침상안정, 활력징후와요배출량의근접관찰, 주기적인복부신체검사및헤모글로빈검사를시행해야하며, 필요한경우는수혈을시행할수있다 [17,18]. 관통성손상의경우에는상처의오염을방지하기위하여, 둔상성손상의경우에는, 다량의후복막혈종혹은요누출이있는경우, 합병증방지를위하여항생제치료를고려할수있다 [6,18,24,27]. Wessells 등은보존적치료를시행한모든 grade IV, V와비활력분절을동반한 grade III 환자는손상 2-3일후, 그리고혈류역학적으로불안정해지거나, 수혈과혈관경색술에도불구하고지속적인헤모글로빈감소시에전산화단층촬영재시행의필요성을주장하였고, 보행은육안적혈뇨가소실되면가능하고, 격렬한운동은최소 6주동안피해야한다고하였다 [24]. 신손상후발생하는고혈압은신동맥폐쇄, 동정맥기형및혈종의신실질의압박으로인한신허혈이가장큰원인이며, 손상후신기능이 20% 미만으로감소되고전체신장의반흔형성의소견이보이면신적출술을고려할수있다. 본연구에서이러한합병증이발생한환아는없었다.
Young Ho In, et al:conservative Management in Pediatric Renal Trauma 1131 결 저자들은신손상의정도가 grade I부터 III까지는활력징후가안정되어초기에보존적치료가가능하였다. Grade IV 의경우에도지속적인요누출을동반한심한발열이나는경우를제외한다면, 초기에보존적치료가시도가가능하여신손상의보존적치료접근이신장보존과합병증의최소화측면에서안전하고타당한치료법으로생각한다. 하지만활력징후가안정적일지라도지속적인출혈소견이보이며, 요누출로인한증상이호전되지않는다면적극적으로전산화단층촬영과같은검사를시행하고빨리개복수술을고려하는것이나을것으로생각한다. Grade V의경우에는초기에보존적치료를고려하기보다는처음부터적극적으로조기수술을고려하는것이환자의예후에좋을것으로판단되고, 타장기의손상이심하게동반되었다면적극적으로타과와의협진수술을시행하는것이환자의예후에도움이될것으로생각한다. 론 REFERENCES 1. American Academy of Pediatrics Section on Orthopaedics, American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American Academy of Pediatrics Section on Critical Care, American Academy of Pediatrics Section on Surgery, American Academy of Pediatrics Section on Transport Medicine, American Academy of Pediatrics Committee on Pediatric Emergency Medicine, et al. Management of pediatric trauma. Pediatrics 2008;121:849-54. 2. Kim DH, Lee SH, Lee SB, Ryu MH, Lee DJ. Clinical analysis of pediatric death patients visiting emergency center. Korean J Pediatr 2004;47:12-7. 3. Livne PM, Gonzales ET Jr. Genitourinary trauma in children. Urol Clin North Am 1985;12:53-65. 4. Wessel LM, Scholz S, Jester I, Arnold R, Lorenz C, Hosie S, et al. Management of kidney injuries in children with blunt abdominal trauma. J Pediatr Surg 2000;35:1326-30. 5. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, et al. Organ injury scaling: spleen, liver, and kidney. J Truma 1989;29:1664-6. 6. Buckley JC, McAninch JW. Pediatric renal injuries: management guidelines from a 25-year experience. J Urol 2004; 172:687-90. 7. Brown SL, Elder JS, Spirnak JP. Are pediatric patients more susceptible to major renal injury from blunt trauma? A comparative study. J Urol 1998;160:138-40. 8. Lee JH, Yoon SJ, Lee JB. Comparison of blunt renal injury between children and adults: effect of the causes on severity of renal injury. Korean J Urol 2005;46:32-6. 9. Sahin H, Akay AF, Yilmaz G, Tacyildiz IH, Bircan MK. Retrospective analysis of 135 renal trauma cases. Int J Urol 2004;11:332-6. 10. Miller KS, McAninch JW. Radiographic assessment of renal trauma: our 15-year experience. J Urol 1995;154:352-5. 11. Morse TS. Renal injuries. Pediatr Clin North Am 1975;22: 379-91. 12. Chopra P, St-Vil D, Yazbeck S. Blunt renal trauma-blessing in disguise? J Pediatr Surg 2002;37:779-82. 13. Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. J Urol 1996;156: 2014-8. 14. Santucci RA, Langenburg SE, Zachareas MJ. Traumatic hematuria in children can be evaluated as in adults. J Urol 2004; 171:822-5. 15. Hammer CC, Santucci RA. Effect of an institutional policy of nonoperative treatment of grade I to IV renal injuries. J Urol 2003;169:1751-3. 16. Keller MS, Eric Coln C, Garza JJ, Sartorelli KH, Christine Green M, Weber TR. Functional outcome of nonoperatively managed renal injuries in children. J Trauma 2004;57:108-10. 17. Heyns CF. Renal trauma: indications for imaging and surgical exploration. BJU Int 2004;93:1165-70. 18. Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch JW, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int 2004;93:937-54. 19. Cass AS, Luxenberg M. Conservative or immediate surgical management of blunt renal injuries. J Urol 1983;130:11-6. 20. Santucci RA, McAninch JW, Safir M, Mario LA, Service S, Segal MR. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma 2001;50:195-200. 21. Husmann DA, Gilling PJ, Perry MO, Morris JS, Boone TB. Major renal lacerations with a devitalized fragment following blunt abdominal trauma: a comparison between nonoperative (expectant) versus surgical management. J Urol 1993;150: 1774-7. 22. Russell RS, Gomelsky A, McMahon DR, Andrews D, Nasrallah PF. Management of grade IV renal injury in children. J Urol 2001;166:1049-50. 23. Rogers CG, Knight V, MacUra KJ, Ziegfeld S, Paidas CN, Mathews RI. High-grade renal injuries in children-is conservative management possible? Urology 2004;64:574-9. 24. Wessells H, McAninch JW, Meyer A, Bruce J. Criteria for nonoperative treatment of significant penetrating renal lacerations. J Urol 1997;157:24-7. 25. Joung JY, Park SC, Kim JB, Kim HK, Park JY, Cheon SH, et al. Comparison of operative versus conservative management in pediatric renal trauma. Korean J Urol 2005;46:124-30. 26. Altman AL, Haas C, Dinchman KH, Spirnak JP. Selective
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