Initial assessment of efficacy and safety of spinal anesthesia combined with obturator nerve block for transurethral resection of bladder tumor

Nội dung text: Initial assessment of efficacy and safety of spinal anesthesia combined with obturator nerve block for transurethral resection of bladder tumor

1. JOURNAL OF MILITARY PHARMACO-MEDICINE N 07-2016 INITIAL ASSESSMENT OF EFFICACY AND SAFETY OF SPINAL ANESTHESIA COMBINED WITH OBTURATOR NERVE BLOCK FOR TRANSURETHRAL RESECTION OF BLADDER TUMOR Nguyen Trung Kien*; Hoang Van Chuong*; Tran Van Hinh* Nguyen Phu Viet*; Pham Quang Vinh* SUMMARY Objectives: To assess the efficacy and safety of spinal anesthesia combined with obturator nerve block (ONB) for transurethral resection of bladder tumor. Subjects and methods: A prospective study was carried out on 10 patients who underwent spinal anesthesia combined with ONB using nerve stimulation for transurethral resection of bladder tumor. Quality of anesthesia, violent adductor contraction and inadvertent bladder perforation as well as side effects were monitored. Results: All patients had an excellent quality of anesthesia, distance from skin to obturator nerve was 2.6 ± 1.4 cm on everage, 9 patients were absent of leg jerking. Side effects included shiving in 2 cases, hypotension in 1 case and bradycardia in 1 case. Conclusion: Combination of spinal anesthesia and ONB provided good effective anesthesia for transurethral resection of bladder tumor: adductors muscle spasms were absent in 90%, side effects were transient and mild. * Key words: Bladder tumor; Spinal anesthesia; Obturator nerve block; Transurethral resection of bladder tumor. INTRODUCTION and ONB for transurethral resection bladder Bladder cancer is the fourth most tumor. common cancer in men in the world. The SUBJECTS AND METHODS obturator nerve may be accidentally 1. Methods. stimulated during transurethral resection A prospective study was conducted of lateral bladder wall tumors, causing adductor contraction. Spinal anesthesia is from 6 - 2015 to 6 - 2016 to assess the a favoured anaesthetic technique but the efficacy and safety of combination of rate of adductor spasm can get as high as spinal aneshthesia and ONB using nerve 40% [3]. That is also the main reason stimulator in 10 patients who underwent leading to bladder wall perforation and transurethral resection bladder tumor. increase morbidity. Methods of - The patients were admitted into preventing the stimulation of the obturator operating room, and established intravenous nerve include: reduction of the access for 0.9% of NaCl infusion. Constant electrocautery power, bipolar resection, monitoring was ensured of ECG, heart general anesthesia, or ONB following rate, pulse oxymetry (SpO 2); non-invasive spinal anesthesia [8]. The objective of this blood pressure measurements were taken study is: To assess the efficacy and every 2.5 minutes; oxygen was delivered safety of combination of spinal anesthesia 3l/mins via facemask. * 103 Hospital Corresponding: Nguyen Trung Kien (drkien103@gmail.com) 66
2. JOURNAL OF MILITARY PHARMACO-MEDICINE N 07-2016 - Spinal anesthesia was performed in blocked conduction in the sensory nerve the sitting position, most frequently in the fibers of the bladder, the patient was L3-L4 or L 2-L3 space with the dose of 8 - placed in the obstetric position. 10 mg of hyperbaric bupivacaine 0.5% - The quality of anesthesia was judged depending on the patient’s status and 20 on a 4 point scales as: mcg of fentanyl. Betadine was used for + Excellent: no pain or sensation. skin antisepsis before inserting the spinal + Good: mild pain or discomfort. needle. + Fair: mild discomfort that required - 25G spinal needle was inserted, analgesia. when cerebral spinal fluid was free, the mixture of bupivacaine - fentanyl was + Poor: patient in moderate or severe slowly injected into intrathecal space and pain that required general anaesthesia. then placed in the supine position. - The duration of spinal anaesthesia - Bilateral ONB was then performed: a was defined as the period from spinal 100 mm long stimuplex needle (B. Braun, injection to the first time when the patient Melsungen, Germany) that was connected requested for analgesia in the postoperative to a stimulating current at 2 mA was inserted period. 2 cm caudally and laterally to the pubic - Monitor degree of motor block by tubercle. The needle was then slowly Bromage scale: introduced below the horizontal remus of + Grade 0: no motor block. the pubis and inserted deeper until its tip + Grade 1: inability to raise extended laid in the obturator canal. The optimal leg; able to move knees and feet. needle position was reached when the minimal stimulating current (< 0.5 mA) + Grade 2: inability to raise extended induced adductor spasm. Once this position leg and move knee; able to move feet. was reached, 10 mL of 2% lidocaine were + Grade 3: complete block of motor limb. injected. The whole procedure was repeated - Monitor the distance from skin to the on the other side. abturator nerve; quality of ONB. - Transurethral resection bladder tumor + Good: no reflexes from the obturator procedure was performed. nerve during procedure. - Materials and devices: stimulex HNS + Bad: had any reflexes from the 12, B.Braun; 100 mm long stimulex needle; obturator nerve during procedure, bladder monitor Nihon Kohden (Japan). perforation during electroresection and 2. Some terms were used in the other complications. study. - Hypotension is difined as a fall in - Sensory block level on the skin was blood pressure of more than 20% below assessed by Pin-prick test. Upon reaching the preoperative blood pressure or a mean the appropriate anesthesia level T 10 , which arterial pressure of less than 60 mmHg. 67
3. JOURNAL OF MILITARY PHARMACO-MEDICINE N 07-2016 RESULTS 1. Patient and surgical demographics. Table 1: Patient and surgical demographics. Result (n = 10) Gender: male/female 8/2 Age (mean ± SD) 48.5 ± 17.6 [42 - 69] BMI (kg/m 2) (mean ± SD) 21.3 ± 3.4 [18.2 - 24.8] ASA grade: 1/2/3/4/5/6 4/3/2/0/0 Duration of taking ONB (minutes) (mean ± SD) 5.4 ± 3.7 [2.5 - 8.3] Distance from skin to obturator nerve (cm, mean ± SD) 2.6 ± 1.4 [2.3 - 4.2] Bilateral ONB/unilateral ONB block 10/0 Bromage score 0/1/2/3 ten minutes after spinal block 0/0/0/9 Quality of spinal anesthesia (n) 10/0/0/0 Excelent/good/mild/fair Duration of spinal anesthesia (minutes) (mean ± SD) 226.8 ± 37.5 2. Other perioperative characteristics. Table 2: Result Adductor muscle contraction n (%) No 9 (90%) Moderate 1 (10%) Severe 0 Operation time (minutes, mean ± SD) 22.7 ± 9.3 [18 - 32] Tumor size (mm) (mean ± SD) 5.2 ± 4.9 [2 - 12] Tumor number (n) (mean ± SD) 2.1 ± 1.7 [1 - 4] Bladder perforation (n) (%) 0 Complete resection (n) (%) Yes 9 (90%) No 1 (10%) 3. Vital signs. Respiratory rate, pulse oxymetry (SpO 2,), pulse rate, blood pressure were stable and ranged in normal limitation. * Complications and side effects (n = 4): Shivering: 2 patients (20%); hypotension: 1 patients (10%); bradycardia: 1 patients (10%); nausea: 0 patients (0%); anesthetic toxicity: 0 patients (0%). 68
4. JOURNAL OF MILITARY PHARMACO-MEDICINE N 07-2016 DISCUSSION muscle contraction was detected in 40% An advantage of spinal anesthesia is of patients in group with spinal anesthesia that profound nerve block can be produced but just only 11.4% in group combined in a large part of the body by the relatively spinal anesthesia with ONB. simple injection of a small amount of local The mechanism of adductors’ contraction anesthesia. This technique is commonly during this procedure have been studied. used for transurethral resection of the bladder The sensorimotor nerve arises from the tumor. Also it has an adequate quality of lumbar plexus at L 2-L4 and in the lesser anesthesia for most kinds of intervention pelvis, it is adjacent to the obturator fascia, in urology, but it can not prevent bladder which covers the outer part of the internal perforation from contracting adductor due obturator muscle. It innervates the muscles to stimulating during transurethral resection responsible for adducting the thigh and of lateral bladder wall tumors. Transurethral the skin on the surface of the paramedian resection of bladder tumors which are segment of the thigh. During transurethral close to these areas may stimulate the resection of the bladder tumor, when the obturator nerve, causing violent adductor bladder has been filled with irrigation fluid, contraction and possible inadvertent bladder the obturator nerve is directly adjacent to the perforation. To avoid this reaction, local lateral wall of the bladder. Any unintentional anesthetic blockade of the obturator nerve stimulation during electroresection results as it passes through the obturator canal is in the adductors’ contraction and resultant effective in stopping adductor spasm during sudden leg movement, which may in turn spinal anesthesia [4]. Thus, we had an initial lead to extraperitoneal perforation of the assessment efficacy of spinal anesthesia bladder wall with the resectoscope loop. combined with ONB for this kind of surgery Adductors’ contraction during transurethral at 103 Hospital. resection can cause major complications In our study, mean age was in labour such as bladder perforation, obturator artery age and male had a higher rate than injury. We did not have any complications female. The distance from skin to due to small size of study (n = 10)... Akata obturator nerve was 2.6 ± 1.4 cm on the T had a case report with life-threatening sagittal plane and the pubic tubercle haemorrhage following obturator artery (Table 1 ). This result is similar to Locher’s injury during transurethral bladder surgery results when he studied in ten cadavers as a sequel of an unsuccessful ONB. (ranged from 1 to 3.8 cm) [6]. There were According to this result, in spite of prior 10 patients who needed bilateral ONB blockade of the obturator nerve with 1% because two sides wall bladder of the mepivacaine (8 mL) utilizing a nerve tumor located; of which 9 patients had not stimulator, violent leg jerking was evoked seen adductor muscle contraction, but 1 during transurethral electroresection of a case still had slight contraction of adductor bladder tumor approximately 1 hour after muscle although the quality of anesthesia the blockade. He noticed that the patient was excellent in all patients ( table 2 ). became severely hypotensive right after According to Bolat (2015) [3], adductor following the jerking, and a large lower 69
5. JOURNAL OF MILITARY PHARMACO-MEDICINE N 07-2016 abdominal swelling concurrently developed. inguinal approach and the rate of success The urgent laparotomy indicated that the was 90%. In Tatlisen. A’s study [7], muscle left obturator artery was severely injured spasms were absent in 97% (n = 61) with by the resectoscope associated with the nerve stimulation guided for ONB. bladder perforation, causing acute massive Another study by Hizli F [4] was carried haemorrhage [1]. Thus, combining spinal out on 41 patients who underwent anesthesia with ONB brought much benefit transurethral resection of bladder tumor for this procedure. with spinal anesthesia combined with Volume and concentration of anesthetic ONB. After spinal anesthesia, ONB was solution are important factors for getting performed with an inguinal approach success in prevention of the obturator (n = 21) or an intravesical approach nerve stimulation during the transurethral (n = 20). In this study, 10 ml of 2% procedures. We had an unsucessfull lidocaine was used to perform the ONB. case because in this patient we injected The efficacy of ONB was significantly two sites and this was not enough higher in inguinal approach group compared anesthetic solution to cover obturator to intravesical approach group. The study nerve. Akata T [1] found that, in order to by Khorrami M [5] has shown that ONB attain profound blockade of the motor using stimulation guided took 5.2 to 6.7 neuron fibres of the obturator nerve and minutes on everage. This time in my thereby prevent the thigh-adductor study was 5.4 ± 3.7 minutes. In general, muscle contraction which could lead to it’s more accurate to determine the obturator life-threatening situations, larger volume nerve with nerve stimulation rather than of a higher concentration of local blind technique. anaesthetic with a longer duration should Complications were not seen in the be used, even with a nerve stimulator, in the study. Side effects were transient and mild ONB for the transurethral procedures. But included shiving 20%, hypotension 10%, failure in ONB was sometimes due to bradycardia 10%. accessory obturator nerve that was CONCLUSION presented in 10 - 30% of patients. Thus, it was clinically important that it was also Combination of spinal anesthesia and considered during ONB. According to ONB provided good effective anesthesia Akkaya [2], the mean accessory obturator for transurethral bladder tumor surgery: nerve-pubic tubercle distance was 4 cm. adductors muscle spasms were absent in When the needle was classically penetrated 90%, side effects were transient and mild. into the obturator nerve to gain access to REFERENCES the accessory obturator nerve. 1. Akata T, Murakami J, Yoshinaga A . Life- Obturator nerve could be blocked threatening haemorrhage following obturator through inguinal approach or intravesical artery injury during transurethral bladder surgery: approach which had a different result a sequel of an unsuccessful ONB. Acta Anaesthesiol Scand. 1999, 43 (7), pp.784-748. in block. We assessed this nerve via 70
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