局部麻醉下输尿管软镜碎石术围手术期管理的研究进展

Research advance on the perioperative management of flexible ureteral lithotripsy under local anesthesia

摘要

全身麻醉（GA）下输尿管软镜碎石术（FURL）在肾结石及输尿管上段结石的治疗中占据着重要地位，但部分患者无法耐受GA。局部麻醉（LA）因其安全性及有效性，近年来在临床上已逐渐成为GA的可行替代方式，也是部分≤20 mm、结石脆性较高、计算机断层扫描值较低、配合度较高人群的可选麻醉方式。术前完善相关检查、评估患者状态、进行抗感染预防，以及留置输尿管支架对LA下FURL的成功实施具有重要意义。术中需根据患者的具体情况灵活选择截石位、剪刀位、俯卧分腿位等体位，使用LA药物控制患者的生理疼痛、缓解心理焦虑，关注并调控患者的呼吸状态，同时选用合适的输尿管镜及镜鞘，为手术的成功实施与安全保驾护航。本文对LA下FURL围手术期管理进行了简要总结，为临床提供参考。

Abstract

Flexible ureteral lithotripsy (FURL) under general anesthesia (GA) is the dominant method in the treatment of renal and upper ureteral calculi, but some patients cannot tolerate GA. In recent years, there has been a growing interest in the use of local anesthesia (LA) as a safe and effective alternative. And it is also an option for patients who have calculi ≤20 mm with high fragility, lower CT value and better compatibility. Before surgery, it is important to conduct relevant examinations, evaluate the status of patients, prevent infections, and indwell ureteral stents. During surgery, lithotomy position, scissors position, prone leg position and other positions should be selected according to the specific conditions of patients. LA drugs should be used to control physiological pain and relieve psychological anxiety. Patients' breathing state should be carefully monitored, and appropriate ureteroscope and lens sheath should be selected for the success and safety of the operation. In this paper, the perioperative management of FURL under LA is briefly summarized, so as to provide reference for clinical practice.

关键词

泌尿系结石 / 输尿管软镜碎石术 / 局部麻醉 / 全身麻醉 / 围手术期管理 / 快速康复理念 / 视觉模拟评分 / 高危患者 / 结石清除率

Key words

urinary calculi / flexible ureteral lithotripsy / local anesthesia / general anesthesia / perioperative management / enhanced recovery after surgery / visual analogue scale / high-risk patients / stone-free rate

参考文献

[1] 米华， 邓耀良. 中国尿石症的流行病学特征[J]. 中华泌尿外科杂志， 2003， 24（10）： 715-716.

[2] 曾国华， 麦赞林， 夏术阶， 等. 中国成年人群尿石症患病率横断面调查[J]. 中华泌尿外科杂志， 2015， 36（7）： 528-532.

[3] 中华医学会泌尿外科分会， 中国泌尿系结石联盟. 软性输尿管镜术中国专家共识[J]. 中华泌尿外科杂志， 2016， 37（8）： 561-565.

[4] SCALES CD JR, TASIAN GE, SCHWADERER AL, et al. Urinary stone disease: advancing knowledge, patient care, and population health[J]. Clin J Am Soc Nephrol, 2016, 11(7): 1305-1312.

[5] TÜRK C, PETRˇÍK A, SARICA K, et al. EAU guidelines on interventional treatment for urolithiasis[J]. Eur Urol, 2016, 69(3): 475-482.

[6] HE M, DONG Y, CAI W, et al. Recent advances in the treatment of renal stones using flexible ureteroscopys[J]. Int J Surg, 2024, 110(7): 4320-4328.

[7] UNAL O, MEHMET C, FATIH A, et al. Comparison of safety and efficiency of general, spinal and epidural anesthesia methods used for the endoscopic surgical treatment of ureteral stones: which one is better to access the ureter and reach the stone?[J]. Urol J, 2020, 17(3): 237-242.

[8] WANG W, GAO X, MA Y, et al. Regional vs. general anesthesia for retrograde intrarenal surgery: a systematic review and meta-analysis[J]. J Endourol, 2020, 34(11): 1121-1128.

[9] CAI H, WU X, CHEN X, et al. Comparison of the effects of general, spinal and epidural anesthesia on ureter access and surgical outcomes during flexible ureterorenoscopy for transurethral single stone removal surgeries: a monocentric retrospective study[J]. Ann Med, 2021, 53(1): 2110-2119.

[10] UNAL O, MEHMET C, VOLKAN S, et al. Do anesthesia methods in retrograde intrarenal surgery make difference regarding the success of ureteral access and surgical outcomes?[J]. J Laparoendosc Adv Surg Tech A, 2020, 30(3): 273-277.

[11] SAHAN M, SARILAR O, AKBULUT MF, et al. Flexible ureterorenoscopy and laser lithotripsy with regional anesthesia vs. general anesthesia: a prospective randomized study[J]. Int Braz J Urol, 46(6): 1010-1018.

[12] 王宁， 刘慧倩， 唐永玺， 等. 局麻输尿管软镜钬激光碎石取石术治疗高危上尿路结石患者疗效观察[J]. 临床泌尿外科杂志， 2022， 37（8）： 620-625.

[13] PENG Y, WANG L, JIN J, et al. Flexible ureteroscopy under local anesthesia for stone management: initial exploration and two-year experience[J]. Postgrad Med, 2023, 135(7): 755-762.

[14] ATɪLGAN D, KÖLÜKÇÜ E, FɪRAT F, et al. Efficacy and safety of holmium laser lithotripsy under local anesthesia in the treatment of urethral stones in elderly male patients[J]. Healthcare (Basel), 2020, 8(2): 150.

[15] 谢天朋， 孙昊， 王晓宁， 等. 局麻下输尿管软镜碎石术在高危上尿路结石患者中的应用[J]. 赣南医学院学报， 2022， 42（7）： 687-689， 705.

[16] MATTHEWS VINEETA, AMELIA P, et al. Outcomes of loco-regional anaesthesia in ureteroscopy for stone disease: a systematic review[J]. Curr Opin Neuro, 2020, 30(5): 726-734.

[17] 王宁， 刘慧倩， 姚俊杰， 等. 局麻输尿管软镜疗效观察及围手术期疼痛危险因素分析[J]. 现代泌尿外科杂志： 2022， 37（8）： 620-625.

[18] WANG P, MA S, WANG X. Relationship between stone volume, average CT value and operation time and efficiency before ureteral soft lens laser lithotripsy[J]. Technol Health Care, 2024, 32(6): 4603-4612.

[19] ANIL S, BAIKUNTHA A, FREDERIC P, et al. Flexible ureteroscopy for lower pole calculus: is it still a challenge?[J]. World J Urol, 2023, 41(11): 3345-3353.

[20] 崔振宇， 杨文增， 周洪月， 等. 组合式输尿管软镜一期治疗双侧＜1.5 cm肾结石的安全性及有效性分析[J]. 中国内镜杂志， 2017， 23（6）： 102-104.

[21] 詹扬， 戴廷山， 范振永， 等. 肾结石老年患者输尿管软镜治疗后重复手术和结石相关事件的风险因素[J]. 中国老年学杂志， 2023， 43（17）： 4170-4173.

[22] 常海， 王林峰， 张高杰， 等. 局麻下可弯曲负压鞘联合输尿管软镜治疗≥3 cm肾结石的有效性和安全性研究[J]. 重庆医科大学学报， 2024， 49（6）： 669-673.

[23] 刘慧倩， 王宁， 姚俊杰， 等. 局部麻醉和全身麻醉下输尿管软镜碎石术治疗上尿路结石的临床疗效比较[J]. 重庆医学， 2023， 52（19）： 2971-2976， 2982.

[24] 王金河. 结石CT值对输尿管软镜钬激光清除单发肾结石效果的预测作用[J]. 应用激光， 2019， 39（5）： 905-908.

[25] KOO KC, YOON JH, PARK NC, et al. The Impact of preoperative α-adrenergic antagonists on ureteral access sheath insertion force and the upper limit of force required to avoid ureteral mucosal injury: a randomized controlled study[J]. J Urol, 2018, 199(6): 1622-1630.

[26] 唐永玺. 1.局麻下双镜联合治疗高危复杂性肾结石14例疗效分析；2.俯卧分腿位下输尿管软镜治疗复杂输尿管上段结石疗效观察[D]. 重庆医科大学， 2022.

[27] 刘桂莲， 易继群， 聂爱萍， 等. 精细化护理在局麻下行输尿管软镜碎石术治疗上尿路结石中的效果[J]. 实用临床医学， 2023， 24（1）： 83-85， 91.

[28] 吴玉贵， 钟绍东， 曾新建， 等. 间歇通气呼吸暂停联合低PEEP通气在肥胖患者输尿管软镜术中的应用[J]. 江西医药， 2021， 56（3）： 374-376.

[29] 黄剑华， 徐战平， 钟羽翔， 等. 低呼吸频率低潮气量通气全麻用于输尿管软镜碎石术的随机对照研究[J]. 中国微创外科杂志， 2019， 19（10）： 870-873.

[30] ALBA S, EUGENIO V, MARIELA C, et al. A historical comparison of thulium fiber laser systems for stone lithotripsy: navigating toward safe and effective parameters[J]. World J Urol, 2024, 42(1): 145.

[31] HUANG R, CHEN JC, ZHOU YQ, et al. Relocation of lower pole renal stones helps improve the stone-free rate during flexible ureteroscopy with a low complication rate[J]. World J Urol, 2024, 42(1): 30.

[32] YUN JW, SAADA L. 692 does sleep laterality influence kidney stone formation and clearance?-A review of the current literature[J]. Br J Surg, 2021, 108(Supplement 2): znab134.314.

[33] KF WV, KHATEREH A, KHALED A, et al. Controversies associated with ureteral access sheath placement during ureteroscopy[J]. Invest Clin Urol, 2020, 61(5): 455-463.

[34] HAN Z, WANG B, LIU X, et al. Intrarenal pressure study using 7.5 French flexible ureteroscope with or without ureteral access sheath in an ex-vivo porcine kidney model[J]. World J Urol, 2023, 41(11): 3129-3134.

[35] LEE MS, CONNORS BA, AGARWAL DK, et al. Determining the threshold of acute renal parenchymal damage for intrarenal pressure during flexible ureteroscopy using an in vivo pig model[J]. World J Urol, 2022, 40(11): 2675-2681.

[36] SONG B, JIN D, CHENG Y, et al. What is the appropriate gravel size during ureteroscopy lithotripsy? An in vitro evaluation[J]. Urolithiasis, 2023, 51(1): 52.

[37] SHI J, HUANG T, SONG B, et al. The optimal ratio of endoscope-sheath diameter with negative-pressure ureteral access sheath: an in vitro research[J]. World J Urol, 2024, 42(1): 122.

[38] ZHANG Z, LENG S, XIE T, et al. Flexible ureteroscopic lithotripsy with a suctioning ureteral access sheath for removing upper urinary calculi under local anesthesia[J]. Front Surg, 2023, 10: 1242981.

[39] YU Y, CHEN Y, ZHOU X, et al. Comparison of novel flexible and traditional ureteral access sheath in retrograde intrarenal surgery[J]. World J Urol, 2024, 42(1): 7.

[40] 张兆林， 谢天朋， 江波， 等. 末端可弯输尿管吸引鞘联合输尿管软镜在上尿路结石中的应用[J]. 中国微创外科杂志， 2023， 23（8）： 581-586.

[41] 蒋晓峰， 李云智， 金铭， 等. 输尿管软镜碎石术联合可弯曲负压吸引鞘术后无管化治疗＞2 cm上尿路结石的疗效观察[J]. 江苏大学学报（医学版）， 2024， 34（4）： 301-306.

[42] KIM CR, JANG EB, HONG SH, et al. Indwelling urinary catheter assembled with lidocaine-loaded polymeric strand for local sustained alleviation of bladder discomfort[J]. Bioeng Transl Med, 2021, 6(2): e10218.

基金资助

昆明医科大学2023年研究生创新基金项目(2023S405)