局麻下利用软性膀胱镜联合铥激光治疗麻醉高风险膀胱肿瘤患者的经验

Experiences of flexible cystoscopy combined with thulium laser under local anesthesia for the treatment of patients with bladder tumors of high-risk anesthesia

目的探讨高龄、麻醉高风险患者在局麻(尿道黏膜麻醉)或无麻醉下利用膀胱软镜行铥激光膀胱肿瘤切除术(ThuLRBT)治疗的可行性。方法天津医科大学第二医院2020年6月至2022年1月共12例经评估一般状态较差、麻醉手术风险较大的高龄膀胱癌患者,利用膀胱软镜行局麻下铥激光膀胱肿瘤切除治疗。术前利用麻醉分级、Essen卒中风险评分量表、运动耐量、改良心脏危险指数评分及心脏并发症发生率综合评估患者全麻术中及术后风险,利用Karnofsky功能状态评分标准、年龄校正察尔森合并症指数及衰弱筛查量表评分数粗略预测术后恢复情况及手术价值。术中即刻利用疼痛数字评分法评估患者耐受情况,同时收集术后尿管留置时间、术后住院时间、并发症发生情况等。术后随访至2023年1月或患者复发。结果所有患者术中均未出现闭孔神经反射及膀胱穿孔等并发症,术后未出现持续膀胱出血及膀胱填塞。即刻疼痛评分(NRS)0~7分,中位评分2分。所有患者均可耐受手术过程,且痛苦较小。术后中位尿管留置时间2 d。术后中位住院时间2 d。术后12例患者定期随访,随访时间3~19个月,其中1例失访,1例患者术后5个月复发,1例患者术后13个月复发。结论ThuLRBT治疗麻醉高风险的高龄膀胱肿瘤患者是一种相对安全有效的治疗方式,其并发症少,患者耐受良好,近期疗效满意。

ObjectiveTo investigate the feasibility of thulium laser bladder tumor resection using cystoscopy under local anesthesia (urethral mucosal anesthesia) or no anesthesia in elderly patients with high risk of anesthesia, and to find an appropriate and effective treatment method for these special patients.MethodsBetween June 2020 and January 2022, 12 elderly patients in the Second Hospital of Tianjin Medical University with bladder cancer accompanied with severe comorbidity underwent thulium laser transurethral resection of bladder tumor using a flexible cystoscope under local anaesthesia. Preoperative assessment of intraoperative and post-operative risk using anesthesia classification standard, Essen stroke risk scale, exercise tolerance, revised cardiac risk index and cardiac complication rate, and crude prediction of post-operative recovery and surgical value using Karnofsky performance functional status scale, age-adjusted charlson comorbidity index score and the frailty screening scale, the status of patients were assessed immediately after surgery. Patients were assessed for tolerance by the numerical rating scale immediately intraoperatively, while the data of the duration of urinary catheter retention, postoperative hospital stay and complications were collected postoperatively. The patients were followed to January 2023 or disease recurrence.ResultsAll patients had no intraoperative obturator nerve reflexes or bladder perforationm, no persistent bladder bleeding or bladder tamponade postoperatively. Immediate pain scores ranged from 0-7 with a mdian of 2. All patients tolerated the procedure with less pain, the median duration of postoperative urethral catheterization was 2 days. The median postoperative hospital stay was 2 days. Twelve patients were followed up regularly with a follow-up period of 3-19 months;one patient was lost, one patient recurred 5 months after surgery and one patient recurred 13 months after surgery.ConclusionsIt's a relatively safe and effective way of treating high-risk patients with bladder cancer who are at high risk of anaesthesia by ThuLRBT under local anaesthetic using a flexible cystoscope, with few complications, good patient tolerance and satisfactory recent outcomes.