膀胱穿刺局部麻醉预防膀胱侧壁肿瘤电切术中闭孔神经反射的效果观察

Prevention of obturator nerve reflex by local anesthesia for bladder puncture in patients with tumor at bladder lateral wall treated with transurethral resection

目的 探讨膀胱穿刺局部麻醉在膀胱侧壁肿瘤行经尿道电切时对闭孔神经反射的预防作用。方法 在硬膜外麻醉的基础上,根据是否行膀胱穿刺局部麻醉将患者分为观察组和对照组,观察组23例,对照组19例。观察组先充盈膀胱约400 ml,在耻骨上缘2 cm处以18 G经皮肾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,分别于上、下、左、右距肿瘤基底部边缘1 cm处刺入2 cm深,针尖达到膀胱肌层外,退出针芯,回抽无血后通过针鞘注射1%利多卡因约5 ml。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。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膀胱内液体,减少电切环伸出距离,降低患侧下肢高度,电凝肿瘤周围膀胱壁再行电切等方法。结果 观察组2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<0.01);观察组/对照组:膀胱穿孔0/3例,留置尿管>7 d者6/5例,二次电切0/2例,以上P值均>0.05。结论 应用膀胱穿刺局部麻醉操作简单,效果可靠,可有效避免闭孔神经反射等并发症的发生,增加手术安全性,提高手术效果。

Objective To investigate the preventive effect of local anesthesia of bladder puncture on obturator nerve reflex in transurethral resection of bladder lateral wall tumor.Methods On the basis of epidural anesthesia,the patients were divided into observation group and control group according to whether local anesthesia of bladder puncture was performed.There were 23 cases in observation group and 19 cases in control group.In the observation group,the bladder was first filled with about 400 ml,and then the bladder was punctured with 18 G percutaneous renal puncture needle at 2 cm of the upper edge of the pubis.Under the monitoring of the electrocision,the puncture needle was inclined to the affected side,and the needle was punctured at 1cm from the upper,lower,left and right sides to the edge of the base of the tumor,and the needle tip reached out of the bladder muscle layer,and the needle core was withdrawn.After no blood was drawn back,about 5 ml of 1%lidocaine was injected through the needle sheath.Finally,10 ml of 1%lidocaine was injected 2 cm above the ureteral opening to block the obturator nerve.Then the tumor was resected by conventional methods.In the control group,no local anesthesia was used.During the removal of the lateral wall tumor,the methods of reducing the fluid in the bladder,reducing the extended distance of the electrocautery ring,reducing the height of the lower limbs on the affected side,and electrocautery of the bladder wall around the tumor were used.Results Obturator nerve reflex occurred in 2 cases of the observation group and 13 cases of the control group(P<0.01).In the observation group/control group,there were 0/3 cases of bladder perforation,6/5 cases of indwelling catheter for more than 7 days,and 0/2 cases of secondary electric resection,(all P>0.05).Conclusion The local anesthesia of bladder puncture is simple and effective,which can effectively avoid the occurrence of complications such as obturator nerve reflex,increase the safety of operation and improve the effect of operation.