膀胱肿瘤等离子电切术中预防闭孔神经反射的手术方式研究

Operation mode to prevent obturator nerve reflex in plasmakinetic resection of bladder tumor

目的探讨等离子电切环预激发法与翻转电切环侧切法在经尿道膀胱肿瘤等离子电切术中预防闭孔神经反射的可行性和临床疗效。方法回顾性分析2015年1月至2018年8月收治的186例膀胱肿瘤患者的临床资料,男112例,女74例。年龄35~83岁,平均(59±11)岁。间断性肉眼血尿76例,查体发现膀胱肿瘤110例。术前均行IVU或CTU检查,未发现合并上尿路肿瘤,且无上尿路其他合并症。术前均行超声、CT(平扫/增强)检查,均未发现临床转移。膀胱镜活检病理均诊断为膀胱尿路上皮癌,肿瘤单发135例,多发51例;临床分期为Ta期105例,T1期81例。186例均在硬膜外麻醉下行经尿道膀胱肿瘤等离子电切术。术中为预防闭孔神经反射,分别采用等离子电切环预激发(预激发组)和翻转电切环侧切(侧切组)技术。预激发组142例,男87例,女55例;年龄42~78岁;肿瘤单发103例,多发39例;肿瘤位于膀胱左侧壁或右侧壁122例(85.9%)、顶壁31例(21.8%)、后壁33例(23.2%)、三角区14例(9.8%)、颈部12例(8.5%);肿瘤分期为Ta期79例,T1期63例;肿瘤最大径5~46 mm。侧切组44例,男25例,女19例;年龄35~83岁;肿瘤单发32例,多发12例;肿瘤位于膀胱左侧壁或右侧壁36例(81.8%)、顶壁13例(29.5%)、后壁10例(22.7%)、三角区5例(11.4%)、颈部4例(9.1%);肿瘤分期为Ta期26例,T1期18例;肿瘤最大径5~40 mm。两组资料比较差异均无统计学意义(P>0.05)。预激发组先采用电切环常规切除肿瘤,术中切除至闭孔神经映射区时,电切环远离肿瘤时即将脚踏开关踩下,使电切环激发,移至肿瘤位置切割肿瘤组织直至肌层,电灼创面周围2 cm并确切止血后结束手术。侧切组先采用电切环常规切除肿瘤,术中切除至闭孔神经映射区时,用电切环侧边切割剩余肿瘤组织直至肌层,一旦发生闭孔神经反射即关闭能量,减少电切环造成的损伤。比较两组的手术时间、闭孔神经反射发生率、膀胱穿孔发生率、出血量、尿管留置时间、住院时间、术后病理分级、肿瘤危险度分级及术后6个月肿瘤复发率。结果两组手术均顺利完成,无中转开放情况。预激发组的手术时间为10~56 min,平均(28±12)min;术中失血量5~70 ml,平均(35±15)ml。侧切组手术时间为15~65 min,平均(28±11)min;术中失血量10~80 ml,平均(40±15)ml。两组手术时间、术中失血量比较差异无统计学意义(P>0.05)。预激发组3例术中发生闭孔神经反射,发生率2.1%;侧切组13例术中发生闭孔神经反射,发生率29.5%,两组比较差异有统计学意义(P<0.05)。预激发组术后病理分级低级别104例,高级别38例;肿瘤危险度分级低危59例,中危57例,高危26例。侧切组术后病理分级低级别37例,高级别7例;肿瘤危险度分级低危16例,中危19例,高危9例。两组比较差异无统计学意义(P>0.05)。预激发组术后尿管留置时间(2.1±0.4)d,住院时间(2.7±0.5)d;侧切组术后尿管留置时间(3.8±0.3)d,住院时间(4.9±0.3)d,两组比较差异均有统计学意义(P<0.05)。术后6个月膀胱肿瘤复发14例,均为高危者,其中预激发组10例(7.1%),侧切组4例(9.1%),两组比较差异无统计学意义(P>0.05)。结论经尿道膀胱肿瘤等离子电切术中,采用等离子电切环预激发法能够有效避免闭孔神经反射,使手术更安全。

Objective To observe the results and reality of transurethral resection of bladder tumor with preexcitation of electric cutting loop in the prevention of obturator nerve reflex.Methods The clinical data of 186 patients with bladder tumors admitted from January 2015 to August 2018 were retrospectively analyzed.There were 112 males and 74 females aged 35 to 83 years,average(59±11)years.76 patients were admitted because of intermittent gross hematuria and 110 patients were admitted because of physical check-up.All patients underwent ultrasound,CT(plain scan/enhancement)and cystoscopy before operation.The pathological diagnosis of cystoscopy biopsy was bladder urothelial cell carcinoma.There were 105 cases clinical stage Ta stage,81 cases of T1 stage.There were 103 single cases and 39 multiple cases of non-muscular invasive bladder.According to the different surgical techniques,the patients were divided into two groups:the pre-excitation group and lateral incision group.There were 142 cases in pre-excitation group.In the pre-excitation group,the tumors were removed routinely by the resection ring.When the resection ring was far away from the tumors,the pedal switch was pressed to excite the resection ring.The resection ring was moved to the location of the tumors,and the tumors were cut to the muscular layer.The operation was completed after 2 cm electric cauterization around the wound and hemostasis.In the lateral incision group,the tumors were removed routinely by the electric resection ring.The operation time,incidence of obturator nerve reflex,incidence of bladder perforation,amount of bleeding,retention time of catheter,pathological grading,risk grading,hospitalization time and recurrence rate of tumors at 6 months after operation were compared between the two groups.Results The operation was successfully completed in both groups,and there was no transition to open operation.In the pre-excitation group,the operation time was 10 minutes to 56 minutes,with an average of(28±12)minutes,and the intraoperative blood loss ranged from 5 ml to 70 ml,with an average of(35±15)ml.In the lateral incision group,the operation time was 15 minutes to 65 minutes,with an average of(28±11)minutes,and the blood loss was 10 ml to 80 ml,with an average of(40±15)ml.There was no significant difference in operation time and blood loss between the two groups(P>0.05).There were only 3 cases of obturator nerve reflex in preexcitation group,the incidence was 2.1%.There were 13 cases of obturator nerve reflex in lateral resection group,the incidence was 29.5%.There was significant difference of nerve reflex incidence between the two groups(P<0.05).Conclusions In transurethral resection of bladder tumors,the method of pre-excitation of plasma resection ring can effectively decrease obturator nerve reflex and make the operation safer.