压力性耐痛阈协助评估经会阴前列腺穿刺局麻效果的可行性

The feasibility of pressure pain tolerance threshold to assist in the selection of anesthesia for transperineal prostatebiopsy

目的探讨压力性耐痛阈(PTO)评估经会阴前列腺穿刺患者局麻效果的可行性。方法纳入苏北人民医院2022年3月至2023年10月行前列腺周围神经阻滞下经会阴前列腺穿刺活检的患者。纳入标准:①直肠指检发现前列腺可疑结节,任何前列腺特异性抗原(PSA);②经直肠前列腺超声(TRUS)或MRI检查发现可疑病灶,任何PSA;③PSA>10ng/ml;④PSA4~10ng/ml,游离/总PSA可疑或PSA密度可疑。满足上述标准之一即可纳入。排除标准:①既往有前列腺穿刺史或前列腺手术史;②严重心脑血管疾病或凝血功能障碍;③严重泌尿系感染;④术前24h内服用止痛药物;⑤不能完成疼痛评分或拒绝配合;⑥直肠指检发现直肠狭窄或直肠其他病变。所有患者均于穿刺术前由同一名医生应用压痛测量仪测量PTO。穿刺术后立即应用视觉模拟评分法(VAS)对患者术中的疼痛情况进行评分。根据VAS评分将患者分为轻度疼痛组(VAS评分为O~3分)和中重度疼痛组(VAS评分为4~10分)。对比两组患者临床资料的差异。进一步分析PTO与VAS评分的相关性。绘制PTO预测穿刺术中疼痛的受试者工作特征(ROC)曲线,利用最大约登指数计算出PTO的最佳截断值。结果本研究共纳入304例患者,其中轻度疼痛组184例,中重度疼痛组120例。轻度疼痛组与中重度疼痛组患者的年龄[69(63,73)岁与69(61,74)岁]、体质量指数[24.0(22.9,25.0)kg/m^(2)与23.9(22.8,24.7)kg/m^(2)]、PSA[14.6(10.5,25.1)ng/ml与14.0(10.5,20.7)ng/ml]、高血压病比例[59.8%(110/184)与64.2%(77/120)]的差异均无统计学意义(P>0.05),两组PT0[(6.69±1.20)kgf/cm^(2)与(5.13±0.92)kgf/cm^(2)]、穿刺针数[19(18,22)针与22(20,24)针]、前列腺体积[36.5(26.6,52.5)ml与63.2(47.4,89.4)ml]、糖尿病比例[35.3%(65/184)与23.3%(28/120)]、有重大外伤史比例[37.5%(69/184)与15.8%(19/120)]的差异均有统计学意义(P<0.05)。PTO与VAS评分呈负相关(r=-0.689,P<0.001)。R0C曲线分析结果显示,PTO的截断值为5.99kgf/cm^(2)时,预测前列腺穿刺术中患者出现轻度或中重度疼痛的准确率最高,此时曲线下面积(AUC)为0.848,约登指数为0.675,敏感性和特异性均较好,分别为89.2%和78.3%。结论经会阴前列腺穿刺患者术前测量的PTO可以评估患者在局麻下对疼痛的耐受情况,当患者PTO≥5.99kgf/cm^(2)时患者的疼痛耐受较好,可在局麻下进行穿刺;当患者PTO<5.99kgf/cm^(2)时患者的疼痛耐受较差,可推荐患者行椎管内麻醉或全麻来减轻穿刺中的痛苦。

Objective To explore the feasibility of pressure tolerance threshold(PTO)in evaluating theeffectof local anesthesia in patients undergoing transperineal prostate biopsy.Methods Patients who underwent periprostatic nerve block prostate biopsy in Northern Jiangsu People's Hospital from March 2022 to October 2023 were prospectively enrolled.Inclusion criteria:①suspicious prostate nodules detected by digital rectal examination,any prostate-specific antigen(PSA)value;②transrectal prostate ultrasound(TRUS)or magnetic resonance imaging(MRI)showing suspicious lesions,any PSA;③the PSA>10 ng/ml;④PSA 4-10 ng/ml,suspicious free/total PSA or suspicious PSA density.Inclusion was required if one of these criteria was met.Exclusion criteria:①previous history of prostate biopsy or prostate surgery;②severe cardiovascular and cerebrovascular diseases or coagulation disorders;③severe urinary tract infection;④taking analgesics within 24 hours before surgery;⑤unable to complete the pain score or refused to cooperate;⑥rectal stenosis or other rectal lesions detected by digital rectal examination.The PTO of all patients was measured by the same physician using a tenderness measuring instrument before puncture.Visual analogue scale(VAS)was used to evaluate the pain during the operation.According to the VAS score,the patients were divided into mild pain group(VAS score O-3 points)and moderate to severe pain group(VAS score 4-10 points).The clinical data of the two groups were compared.The correlation between PTO and VAS score was further analyzed.The receiver operating characteristic(ROC)curve of PTO to predict pain during puncture was drawn,and the optimal cut-off value of PTO was calculated by the maximum Youden index.Results A total of 304 patients were enrolled in this study,including 184 patients in the mild pain group and 120 patients in the moderate to severe pain group.There were no significant differences in age[69(63,73)years old vs.69(61,74)years old],body mass index[24.0(22.9,25.0)kg/m^(2)vs.23.9(22.8,24.7)kg/m^(2)],PSA[14.6(10.5,25.1)ng/ml vs.14.0(10.5,20.7)ng/ml],and hypertension[59.8%(110/184)vs.64.2%(77/120)]between the mild pain group and the moderate to severe pain group(P>0.05),while there were significant differences in PTO[(6.69±1.20)kgf/cm^(2)vs.(5.13±0.92)kgf/cm^(2)],number of puncture needles[19(18,22)needles vs.22(20,24)needles],prostate volume[36.5(26.6,52.5)ml vs.63.2(47.4,89.4)ml],diabetes[35.3%(65/184)vs.23.3%(28/120)],and major trauma experience[37.5%(69/184)vs.15.8%(19/120)](P<0.05).There was a high correlation between PTO and VAS score(r=0.689,P<0.001).ROC curve analysis showed that when PTO was 5.99 kgf/cm^(2),the accuracy of predicting moderate to severe pain during prostate biopsy was the highest.The AUC was 0.848,the Youden index was 0.675,the sensitivity and specificity were 89.2% and 78.3%,respectively.Conclusions PTO can evaluate the effect of local anesthesia in patients undergoing transperineal prostate biopsy.PTO can be measured before surgery in patients undergoing transperineal prostate biopsy.When the patients PTO is≥5.99 kgf/cm^(2),the patient's pain tolerance is better and the local anesthesia effect is feasible.When the patient's PTO is less than 5.99 kgf/cm^(2),the patients pain tolerance is poor,so the patient could be recommended to undergo spinal anesthesia or general anesthesia to reduce the pain during prostate biopsy.