ASA分级≥Ⅲ级患者局麻经会阴前列腺多模态影像融合穿刺的安全性和有效性

doi:10.3877/cma.j.issn.1674-3253.2024.05.004

目的

探讨美国麻醉医师协会（ASA）分级≥Ⅲ级可疑前列腺癌患者在局麻下行经会阴前列腺多参数磁共振-经直肠彩超（mpMRI-TRUS）影像融合靶向穿刺的安全性和有效性。

方法

回顾性分析2023年1月至2023年11月湖南省人民医院收治的151例行经会阴前列腺mpMRI-TRUS影像融合靶向穿刺活检患者的临床病理资料。根据术前ASA分级，将患者分为观察组（ASA分级≥Ⅲ级）和对照组（ASA分级<Ⅲ级）。应用视觉模拟评分（VAS）和视觉数字评分（VNS）评估患者前列腺穿刺活检的疼痛感和麻醉满意度。比较两组患者穿刺活检时（VAS-1和VNS-1）和穿刺术后1 h（VAS-2和VNS-2）的疼痛及满意度评分、围手术期并发症发生率和肿瘤阳性检出率的差异。

结果

本研究151例患者，其中观察组45例，对照组106例。观察组患者年龄（72±8）岁显著高于对照组（67±8）岁（P=0.001）。观察组与对照组患者的前列腺体积[43（21，167）cm³ vs 47（15，186）cm³]、PSA[18.8（3.3，550.2）ng/ml vs 17.6（2.1，457.8）ng/ml]、手术时间[（15±4）min vs（16±3）min]、前列腺穿刺活检时VAS-1[（1.8±0.7）分vs（1.7±0.7）分]与VNS-1[（2.78±0.52）分vs（2.79±0.45）分]、穿刺术后1 h的VAS-2[（1.1±0.6）分vs（1.1±0.5）分]与VNS-2[（3.7±0.5）分vs（3.7±0.4）分]差异均无统计学意义（P>0.05）。观察组PI-RADS评分2、3、4、5分者分别为9、11、8、17例，对照组分别为19、28、21、38例，差异无统计学意义（P>0.05）。观察组与对照组在并发症血尿[19.75%（9/45）vs 20.75%（22/106）]、尿潴留[4.65%（2/43）vs 4.95%（5/101）]和肿瘤阳性检出率[60.00%（27/45） vs 62.26%（66/106）]方面差异无统计学意义（P>0.05）。

结论

对于ASA分级≥Ⅲ级可疑前列腺癌患者，局麻下行经会阴前列腺多模态影像融合靶向穿刺活检是安全、可行的。

关键词: 前列腺癌, ASA分级, 局部麻醉, 经会阴, 靶向穿刺, 多参数磁共振

Objective

To explore the safety and effectiveness of magnetic resonance imaging and transrectal ultrasound image (mpMRI-TRUS) fusion transperineal biopsy technique under local anesthesia for suspected prostate cancer patients with ASA grade Ⅲ or higher.

Method

The clinical and pathological data of 151 patients who underwent mpMRI-TRUS image fusion targeted transperineal biopsy using electromagnetic needle tracking under local anaesthesia in Hunan Provincial People's Hospital (the First Affiliated Hospital of Hunan Normal University) from January 2023 to November 2023 were analyzed retrospectively. According to the preoperative ASA grade, patients were divided into the observation group (ASA grade ≥Ⅲ) and the control group (ASA grade <Ⅲ). Visual analogue scale (VAS) and visual numeric scale (VNS) were used to evaluate the pain and anesthesia satisfaction of patients with prostate biopsy. The pain and satisfaction scores during prostate biopsy (VAS-1 and VNS-1) and 1 hour after biopsy (VAS-2 and VNS-2), the incidence of perioperative complications and the positive detection rate of tumor were compared between the two groups.

Result

There were 151 patients in this study, including 45 patients in the observation group and 106 patients in the control group. The age of patients in the observation group [(72±8) years] was significantly higher than that in the control group [(67±8) years], (P=0.001). The prostate volume [43(21, 167) vs 47(15, 186) cm³], PSA [18.8(3.3, 550.2) vs 17.6(2.1, 457.8) ng/ml], surgical time[(15±4) vs (16±3) min], VAS-1 [(1.8±0.7) vs (1.7±0.7) scores] and VNS-1[(2.78±0.52) vs (2.79±0.45) scores] during prostate biopsy, VAS-2 [(1.1±0.6) vs (1.1±0.5) scores] and VNS-2[(3.7±0.5) vs (3.7±0.4) scores] at 1 hour after biopsy were not significantly different between the observation group and control group (P>0.05). The PI-RADS scores of 2, 3, 4 and 5 in the observation group were 9, 11, 8 and 17 respectively, while those in the control group were 19, 28, 21 and 38 respectively, without significant difference (P>0.05). There was no significant difference between the observation group and the control group in terms of complication hematuria [19.75%(9/45) vs 20.75%(22/106)], urinary retention [4.65%(2/43) vs 4.95%(5/101)] and tumor positive detection rate [60.00%(27/45) vs 62.26%(66/106)] (P>0.05).

Conclusion

For suspected prostate cancer patients with ASA grade Ⅲ or higher, multi-mode image fusion targeted transperineal biopsy technique under local anaesthesia is safe and feasible.

Key words: Prostate cancer, ASA grade, Local anesthesia, Transperineal, Targeted biopsy, mpMRI

图1 VENUS多模态人工智能影像融合超声系统及前列腺穿刺活检配件注：a为VENUS多模态AI影像融合超声系统；b为腔内双平面超声探头；c为前列腺活检针电磁导航追踪系统；d为18 G活检针；e为超声探头穿刺架

图2 "一平面三点"局麻经会阴前列腺靶向穿刺活检图注：a为局麻体表投影标志，扇形半圆轮廓为前列腺穿刺进针区域，三小叉为前列腺神经阻滞进针点；b为体表投影标志放大图；c为前列腺尖部神经阻滞麻醉；d为前列腺左右两侧叶神经阻滞麻醉；e为前列腺精准靶向穿刺，红色区域为靶区病灶

图3 前列腺精准穿刺活检技术示意图注：a为针尖在电磁导航追踪系统引导下抵达靶区病变的外侧缘；b为针尖"贯穿式"穿透靶区病变；c为前列腺系统穿刺活检示意图

表1 观察组（ASA分级≥Ⅲ级）与对照组（ASA分级<Ⅲ级）可疑前列腺癌患者一般资料比较

组别	例数	年龄[岁，(±s)]	前列腺体积[cm³，M(Q)]	PSA[ng/ml，M(Q)]	PI-RADS评分[例(%)]
组别	例数	年龄[岁，(±s)]	前列腺体积[cm³，M(Q)]	PSA[ng/ml，M(Q)]	2	3	4	5
观察组	45	72±8	43(21，167)	18.8(3.3，550.2)	9(20.00)	11(24.44)	8(17.78)	17(37.78)
对照组	106	67±8	47(15，186)	17.6(2.1，457.8)	19(17.92)	28(26.42)	21(19.81)	38(35.85)
统计值		t=3.346	Z=-4.055	Z=1.232	χ²=0.221
P值		0.001	0.135	0.571	0.974

表1 观察组（ASA分级≥Ⅲ级）与对照组（ASA分级<Ⅲ级）可疑前列腺癌患者一般资料比较

组别	例数	年龄[岁，(±s)]	前列腺体积[cm³，M(Q)]	PSA[ng/ml，M(Q)]	PI-RADS评分[例(%)]
组别	例数	年龄[岁，(±s)]	前列腺体积[cm³，M(Q)]	PSA[ng/ml，M(Q)]	2	3	4	5
观察组	45	72±8	43(21，167)	18.8(3.3，550.2)	9(20.00)	11(24.44)	8(17.78)	17(37.78)
对照组	106	67±8	47(15，186)	17.6(2.1，457.8)	19(17.92)	28(26.42)	21(19.81)	38(35.85)
统计值		t=3.346	Z=-4.055	Z=1.232	χ²=0.221
P值		0.001	0.135	0.571	0.974

表2 观察组（ASA分级≥Ⅲ级）与对照组（ASA分级<Ⅲ级）可疑前列腺癌患者围手术期资料及csPCa检出率比较

组别	例数	csPCa检出率[例(%)]	不同PI-RADS评分csPCa检出率[例(%)]				手术时间[min，(±s)]	疼痛评分[分，(±s)]
组别	例数	csPCa检出率[例(%)]	2分	3分	4分	5分	手术时间[min，(±s)]	VAS-1	VAS-2
观察组	45	27(60.00)	2(22.22)	4(36.36)	5(62.50)	16(94.12)	15±4	1.8±0.7	1.1±0.6
对照组	106	66(62.26)	3(15.79)	13(46.43)	13(61.90)	37(97.37)	16±3	1.7±0.7	1.1±0.5
统计值		χ²=0.023	χ²=0.064	χ²=0.101	χ²=0.006	χ²=0.033	t=1.108	t=0.481	t=0.013
P值		0.856	>0.999	0.725	>0.999	0.527	0.270	0.631	0.989
组别	满意度评分[分，(±s)]		围术期并发症[例(%)]
组别	VNS-1	VNS-2	血尿	尿潴留	穿刺区血肿	尿路感染	血精	迷走神经反射	感染性休克
观察组	2.78±0.52	3.7±0.5	9(19.75)	2(4.65)	0(0)	0(0)	0(0)	0(0)	0(0)
对照组	2.79±0.45	3.7±0.4	22(20.75)	5(4.95)	0(0)	0(0)	0(0)	0(0)	0(0)
统计值	t=0.175	t=0.032	χ²=0.008	χ²=0.003	-	-	-	-	-
P值	0.862	0.975	>0.999	>0.999	-	-	-	-	-

表2 观察组（ASA分级≥Ⅲ级）与对照组（ASA分级<Ⅲ级）可疑前列腺癌患者围手术期资料及csPCa检出率比较

组别	例数	csPCa检出率[例(%)]	不同PI-RADS评分csPCa检出率[例(%)]				手术时间[min，(±s)]	疼痛评分[分，(±s)]
组别	例数	csPCa检出率[例(%)]	2分	3分	4分	5分	手术时间[min，(±s)]	VAS-1	VAS-2
观察组	45	27(60.00)	2(22.22)	4(36.36)	5(62.50)	16(94.12)	15±4	1.8±0.7	1.1±0.6
对照组	106	66(62.26)	3(15.79)	13(46.43)	13(61.90)	37(97.37)	16±3	1.7±0.7	1.1±0.5
统计值		χ²=0.023	χ²=0.064	χ²=0.101	χ²=0.006	χ²=0.033	t=1.108	t=0.481	t=0.013
P值		0.856	>0.999	0.725	>0.999	0.527	0.270	0.631	0.989
组别	满意度评分[分，(±s)]		围术期并发症[例(%)]
组别	VNS-1	VNS-2	血尿	尿潴留	穿刺区血肿	尿路感染	血精	迷走神经反射	感染性休克
观察组	2.78±0.52	3.7±0.5	9(19.75)	2(4.65)	0(0)	0(0)	0(0)	0(0)	0(0)
对照组	2.79±0.45	3.7±0.4	22(20.75)	5(4.95)	0(0)	0(0)	0(0)	0(0)	0(0)
统计值	t=0.175	t=0.032	χ²=0.008	χ²=0.003	-	-	-	-	-
P值	0.862	0.975	>0.999	>0.999	-	-	-	-	-

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Safety and effectiveness of multi-mode image fusion targeted transperineal biopsy technique under local anaesthesia in patients with ASA grade ≥Ⅲ

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Safety and effectiveness of multi-mode image fusion targeted transperineal biopsy technique under local anaesthesia in patients with ASA grade ≥Ⅲ