用神经刺激器定位行闭孔神经阻滞

经尿道膀胱肿瘤电切术,可能需要施行同侧闭孔神经阻滞.既往大多凭经验操作,效果不可靠.我们试用神经刺激器定位穿刺注药,现将结果报道如下.     

周围神经刺激器在闭孔神经阻滞中的应用

闭孔神经阻滞是膀胱肿瘤电切手术前预防闭孔神经反射的最有效方法,但由于是盲式操作,临床上麻醉失败或阻滞不全也时有发生.我们利用神经刺激器定位行闭孔神经阻滞取得满意效果,现报道如下.     

超声引导下腹股沟径路闭孔神经阻滞的应用

目的观察超声引导下腹股沟径路闭孔神经阻滞在经尿道膀胱肿瘤电切术中预防闭孔神经反射的临床效果和并发症。方法行经尿道膀胱肿瘤电切术患者50例,随机分为2组：超声引导腹股沟径路闭孔神经阻滞组（UONB组,25例）和传统闭孔神经阻滞组（TONB组,25例）。闭孔神经阻滞前后分别测定阻滞侧大腿内收肌力量。记录两种闭孔神经阻滞方法成功率及副作用发生情况等。结果 UONB组和TONB组患者阻滞侧大腿内收肌力量闭孔神经阻滞后分别为52±7mmHg和66±19mmHg,UONB组显著小于TONB组（P=0.001）。UONB组阻滞成功率为97.4%,显著高于TONB组（74.2%）（P=0.01）。结论超声引导闭孔神经阻滞成功率高,可以安全、有效的预防膀胱肿瘤电切术闭孔神经反射。     

膀胱肿瘤电切术中应用周围神经刺激器监测下行闭孔神经阻滞的体会

目的：观察周围神经阻滞器在闭孔神经阻滞麻醉下膀胱肿瘤电切术中使用的可行性和临床效果。方法：15例在骶丛麻醉下行经尿道膀胱肿瘤电切术（TURBt），术中出现闭孔神经反射时，加用周围神经刺激器在监测下行闭孔神经阻滞麻醉。结果：14例闭孔神经反射消失，1例仍有轻微的内收肌痉挛。加用副闭孔神经阻滞麻醉后，肌肉痉挛消失，继续行TURBt，再无一例发生闭孔神经反射。结论：利用神经刺激器辅助定位行闭孔神经阻滞，可以提高闭孔神经阻滞的成功率和质量，有效地避免在TURBt中因闭孔神经反射导致的膀胱穿孔和神经血管损伤。     

膀胱肿瘤电切术中行闭孔神经阻滞防止闭孔神经反射的效果分析

目的 探讨经尿道膀胱肿瘤电切术中采用闭孔神经阻滞防止闭孔神经反射的临床效果.方法 对214例膀胱癌患者行经尿道电切术,治疗组113例在腰-硬联合麻醉基础上进行闭孔神经阻滞,而对照组101例仅行单纯腰-硬联合麻醉.结果 治疗组闭孔神经反射发生率（9.7%）明显低于对照组（22.8%）（P〈0.05）,两组复发率差异无统计学意义（21.2% vs 25.7%,P＆gt;0.05）.结论 在经尿道膀胱肿瘤电切术中采取闭孔神经阻滞能明显减少闭孔神经反射的发生,提高手术的安全性和有效性,临床效果良好.     

新径路闭孔神经阻滞在经尿道膀胱肿瘤电切术中的应用

目的 探讨新径路闭孔神经阻滞(ONB)在经尿道膀胱肿瘤电切术(TURBT)中预防闭孔神经反射引起的内收肌痉挛.方法 膀胱肿瘤患者54例,均在腰-硬联合麻醉下行TURBT,随机均分为两组,分别采用新径路ONB(N组)和传统ONB(C组).记录第1、2、3次ONB穿刺成功率及并发症等.结果 N组第1次ONB穿刺成功率为92%,明显高于C组的76%(P<0.01),N组和C组分别有3例和5例发生闭孔神经反射.N组仅有1例发生术后穿刺部位疼痛,而C组有4例.结论 新径路ONB是一种简单、易学、并发症少的阻滞方法,可在TURBT中推广.     

经闭孔行闭孔神经阻滞对预防膀胱侧壁肿瘤电切时闭孔神经反射的作用

目的探讨经闭孔行闭孔神经阻滞对预防膀胱侧壁肿瘤电切时闭孔神经反射的作用。方法回顾性分析67例膀胱侧壁浅表性肿瘤行经尿道膀胱肿瘤电切术的患者资料,根据术中是否行闭孔神经阻滞分为闭孔神经阻滞组（35例）和对照组（32例）,其中闭孔神经阻滞组术中辅以经闭孔法闭孔神经阻滞,而对照组未行闭孔神经阻滞。比较两组术中闭孔神经反射发生率、膀胱穿孔率、手术时间、及出血量,并术后随访观察肿瘤的复发情况。结果两组术中电切时间、出血量、术后1年肿瘤复发率均无统计学差异,但闭孔神经阻滞组闭孔神经反射率及膀胱穿孔率较对照组明显降低。结论经闭孔行闭孔神经阻滞能有效预防膀胱侧壁肿瘤电切时闭孔神经反射,可降低膀胱穿孔率,其操作要点是选择准确的穿刺点、掌握好穿刺方向和深度。     

超声引导下闭孔神经阻滞在经尿道膀胱肿瘤电切术中预防闭孔神经反射的效果

目的通过对比不同麻醉方式下闭孔神经反射的发生情况,探讨经尿道膀胱肿瘤电切术中预防闭孔神经反射的有效方式。方法选取需行经尿道膀胱肿瘤电切术的膀胱侧壁肿瘤患者160例,男134例,女26例,ASAⅠ~Ⅲ级,随机分为四组:全凭静脉麻醉组(G组),腰-硬联合麻醉组(C组),腰-硬联合麻醉复合静脉麻醉组(V组),腰-硬联合麻醉复合闭孔神经阻滞(obturator nerve block,ONB)组(O组),每组40例。记录不同麻醉方式下闭孔神经反射的发生情况。结果O组闭孔神经反射发生率(7.5%)明显低于C组(32.5%,P=0.005)和V组(40.0%,P=0.001),与G组闭孔神经反射发生率(5.0%)差异无统计学意义(P=0.644)。结论腰-硬联合麻醉复合闭孔神经阻滞与全凭静脉麻醉均可有效预防闭孔神经反射的发生。     

Interadductor approach to obturator nerve block for transurethral resection procedure: comparison with traditional approach

Purpose. We compared the interadductor approach of obturator nerve block with the traditional approach in terms of the insertion-adductor contraction interval (ICI), success rate, completion of the block, and plasma lidocaine concentration. Methods. An obturator nerve block by the interadductor approach was performed by needle insertion 1 cm behind the adductor longus tendon and 2 cm lateral to the pubic arch in 12 patients, and by the traditional approach in 12 patients. Results. The ICI with the interadductor approach was significantly shorter than that with the traditional approach. The success rate, completion of the block, and plasma lidocaine concentrations were similar with both approaches. Conclusion. The interadductor approach can provide faster identification of the obturator nerve than the traditional approach. Received: January 29, 2001 / Accepted: December 12, 2001     

Successful obturator nerve repairing: Intraoperative sural nerve graft harvesting in endometrium cancer patient

INTRODUCTION

Intraoperative injury of obturator nerve is a rare complication of gynecologic surgeries, it has been reported especially in patients with endometriosis and genitourinary malignancies. Gynecologic patients undergoing open lymphadenectomy are at increased risk of obturator nerve injury.

PRESENTATION OF CASE

A 60-year-old woman with FIGO stage II Grade II endometrial adenocarcinoma underwent bilateral pelvic paraaortic lymphadenectomy. During right obturator lymph node dissection, the right obturator nerve was inadvertently transected with Harmonic scalpel sealing system. The graft was used to anastomose epyneurium of distal segment of obturator nerve to its counterpart in the proximal segment with 10–0 prolen suture.

DISCUSSION

In case of iatrogenic nerve transection, microsurgical end to end tension-free coaptation is advocated. In case of the obturator nerve is fixed and because of the thermal injury end to end alignment can not be achieved, nerve grafting is necessary.

CONCLUSION

According to our knowledge, successful immediate grafting of iatrogenically damaged obturator nerve during pelvic lymphadenectomy in our patient is the third report of such a case, but also it has a unique feature of being the first obturator nerve repairing case after dissected with tissue sealing system which causes large sealed area that does not make it possible to make end-to-end anastomosis without nerve harvesting.     

The obturator nerve block

During transurethral electroresection in the posterolateral bladder neck, trigone and posterior urethra, unintentional contractions of the thigh-adductor muscles may occur due to irritation of the obturator nerve. The sudden displacement of the bladder wall against the cutting loop may cause a perforation of the bladder. The authors describe the topographic relation of the bladder wall to the passage of the obturator nerve in the minor pelvis. The technique of obturator nerve block by local anaesthesia is described and its efficacy is demonstrated in 21 patients.     

Dorsal penile nerve block

BACKGROUND: The dorsal penile nerve block (DPNB) is a common form of regional anaesthesia for circumcisions in children. The safety of this block has been questioned following several case reports of potentially serious complications. METHODS: We performed a retrospective review of all the incidents related to the conduct of this block in our institution over a period of 53 months. RESULTS: A total of 3909 circumcisions were performed under DPNB and nine incidents were recorded. This included two cases of bleeding from the prepuce, two urethral injuries, three haematomas and two drug errors. Two cases required further surgical intervention but all of the patients recovered with no apparent long-term sequelae. CONCLUSIONS: We feel that the DPNB is a safe technique for circumcisions in infants and children.     

经尿道膀胱肿瘤电切术2种麻醉方法的比较

目的探讨双侧闭孔神经阻滞在经尿道膀胱肿瘤电切术（transurethral resection of bladder tumor,TURBt）的安全性与有效性。方法77例膀胱肿瘤按时间顺序分为2组：2003年4月～2004年10月46例为硬膜外麻醉组,2004年10月～2005年7月31例为硬膜外联合闭孔神经阻滞组。比较2组TURBt闭孔神经反射发生率和膀胱穿孔发生率。结果硬膜外麻醉组出现闭孔反射25例（其中强烈反射11例）,闭孔反射发生率为54.3%（25/46）,直接由闭孔反射导致的膀胱穿孔8例,膀胱穿孔发生率17.3%（8/46）;硬膜外联合闭孔神经阻滞组发生轻微闭孔反射3例,发生率9.9%（3/31）,膀胱穿孔发生率3.2%（1/31）,硬膜外麻醉组闭孔神经反射发生率明显高于硬膜外联合闭孔神经阻滞组（χ^2=15.970,P=0.000）;但2组膀胱穿孔发生率分别为17.3%（8/46）、3.2%（1/31）无统计学差异（χ^2=2.359,P=0.125）。结论硬膜外麻醉联合双侧闭孔神经阻滞麻醉能有效地减少闭孔神经反射的发生,提高TURBt的安全性。