肿瘤基底部注射局麻药物在预防膀胱侧壁肿瘤术中闭孔神经反射中的应用

Application of local anesthetic drugs injection into tumor base to prevent obturator nerve reflex during bladder lateral wall tumor surgery

本研究主要探讨于肿瘤基底部注射局麻药物在膀胱侧壁肿瘤行经尿道电切时预防闭孔神经反射的作用。患者术中先行硬膜外麻醉,根据是否行肿瘤基底部注射局麻药物将患者分为观察组和对照组,观察组30例,对照组19例。观察组先充盈膀胱约400 mL左右,在耻骨上缘2 cm处以长穿刺针穿刺进入膀胱,在电切镜的监视下,将穿刺针向患侧倾斜,分别于肿瘤周围分4点、距肿瘤基底部边缘0.5~1 cm处刺入膀胱壁,然后针尖潜行2 cm深,当针尖触碰到骨盆壁时判断达到膀胱肌层外,退出针芯,回抽无血后边退针边注射1%利多卡因约5 mL(溶剂以蒸馏水为佳)。4个点注射完毕后可见肿瘤基底部轻度隆起。最后于输尿管开口外上方2 cm处穿刺注射1%利多卡因10 mL,以阻滞闭孔神经干。然后按常规方法进行肿瘤电切。对照组不进行局部麻醉,在切除侧壁肿瘤时采用减少电切环伸出距离、减少膀胱内液体、电凝肿瘤周围膀胱壁、降低患侧下肢高度再行电切等方法。观察组3例在切除侧壁肿瘤时发生闭孔神经反射,对照组13例发生不同程度闭孔神经反射(P=0);观察组比对照组:膀胱穿孔0/3例,二次电切0/2例,留置尿管>7 d者6/5例,两组比较差异均无统计学意义P>0.05。应用肿瘤基底部局部麻醉可有效避免闭孔神经反射,对提升患者临床疗效发挥积极影响。

This study mainly explored the effect of local anesthesia on the prevention of obturator nerve reflex during transurethral resection of bladder lateral wall tumor. Patients were divided into observation group and control group according to whether local anesthetic was injected into the base of tumor, 30 cases in the observation group and 19 cases in the control group. In the observation group, the bladder was filled with about 400 mL, and a long puncture needle was punctured into the bladder at 2 cm above the pubic bone. Under the monitoring of the resectoscope, the puncture needle was inclined to the affected side, and the puncture needle was inserted into the bladder wall at four points around the tumor and 0.5-1 cm away from the edge of the tumor base, and then the needle tip sneaked 2 cm. When the tip of the needle touches the pelvic wall, it is judged that it reaches the bladder muscle layer. Withdraw the needle core and inject 5 mL of 1% lidocaine(distilled water is the best solvent). After the injection of the four spots, the basal part of the tumor was slightly uplifted. Finally, 10 mL 1% lidocaine was injected 2 cm above the ureteral orifice to block obturator nerve trunk. Then the tumor was resected by conventional method. In the control group, no local anesthesia was used. During the resection of lateral wall tumor, methods such as reducing the extended distance of electric cutting ring, reducing the liquid in the bladder, electrocoagulation of bladder wall around the tumor, reducing the height of the affected side of the lower limb were used. Obturator nerve reflex occurred in 3 cases of the observation group and 13 cases in the control group(P=0);the observation group/control group: 0/3 cases of bladder perforation, 0/2 cases of secondary resection, 6/5 cases of indwelling catheter>7 days, all P>0.05. The application of local anesthesia at the base of tumor can effectively avoid obturator nerve reflex and play a positive role in improving the clinical efficacy of patients.