超声引导下骶孔精准穿刺技术在骶神经调节术中的应用
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摘要
目的:探讨术中超声引导下骶孔精准穿刺技术在骶神经调节术(SNM)中的应用及疗效评估。方法:回顾性分析2017年11月～2018年10月15例在我院行SNM的患者资料。15例患者中,7例采用传统X线透视下十字定位法(对照组);8例采用术中超声引导下骶孔精准穿刺定位法(试验组)。统计两组患者术中C臂透视次数、穿刺进针次数、穿刺成功所需时间、术中调控测试时间、体验阶段起效电压、电极植入位置、永久刺激器植入转换率、并发症发生率及术后排尿日记作为评判指标进行疗效评估。结果:15例手术均由同一名主刀医师顺利完成,两组患者性别、年龄、BMI、骶尾椎变异、尿动力学检查等一般资料比较差异无统计学意义。两组C臂透视次数、穿刺进针次数、穿刺成功所需时间比较差异有统计学意义(P<0.01);两组术中调控测试时间比较差异有统计学意义(P<0.05);两组体验阶段起效电压、电极植入位置、永久刺激器植入转换率及术后切口渗液发生率差异均无统计学意义。对9例接受了Ⅱ期永久刺激器植入术的患者平均随访6个月,症状获得持续缓解,未出现不良反应。结论:术中超声引导下骶孔精准穿刺技术的应用明显减少了C臂透视次数及穿刺进针次数,缩短了穿刺时间,提高了术中测试效率,短期随访结果表明超声定位法安全有效,同时与传统方法相比较,术后切口渗液等并发症发生率并无显著增加。期待进一步随机对照研究验证术中超声引导下骶孔精准穿刺技术的临床疗效。
Objective:To explore the application of ultrasound-guided precise puncture in the sacral neuromodulation(SNM)technique and assess the effectiveness.Method:A total of 15 patients who underwent SNM in the department of urology,Nanfang Hospital between November 2017 and October 2018 were analyzed in the study.They were distributed into control group(seven cases)and experimental group(eight cases).Traditional cross positioning method under X-ray fluoroscopy was used in control group,and intraoperative ultrasound-guided precise puncture method was used in experimental group.Times of X-ray fluoroscopy,number of skin punctures,puncture time,intraoperative testing time,testing phase effective voltage,implantation position,postoperative evaluation period,stageⅡconversion rate,postoperative complications and postoperative voiding diary were analyzed in order to evaluate the clinical efficacy.Result:All the 15 procedures were successfully completed by the same surgeon.There was no significant difference in gender,age,BMI,sacral coccygeal vertebra morphological variation,urodynamics and other general data between the two groups.When comparing the control group and experimental group,the times of X-ray fluoroscopy,the number of skin punctures and the average puncture time showed significant difference(P<0.01);Also significant difference could be found in intraoperative testing time(P<0.05);Nevertheless,no significant difference was found in testing phase effective voltage,implantation position,postoperative evaluation period,stageⅡ conversion rate,postoperative incision exudate.Among the 15 patients,nine underwent stageⅡ procedure,no adverse event was detected during an average follow-up period of 6 months,and they were all satisfied with symptoms relief without recurrence.Conclusion:The application of intraoperative ultrasound-guided precise puncture methods remarkably reduced the times of X-ray fluoroscopy and number of skin punctures,and shorten the puncture time,improved the intraoperative testing efficacy,short-term follow-up indicated that ultrasound-guided puncture was safe and effective.Meanwhile,compared with the traditional methods,no postoperative complication was observed to increase.Looking forward to a further RCT study to verify the clinical effects of intraoperative ultrasound-guided precise puncture methods.
Objective:To explore the application of ultrasound-guided precise puncture in the sacral neuromodulation(SNM)technique and assess the effectiveness.Method:A total of 15 patients who underwent SNM in the department of urology,Nanfang Hospital between November 2017 and October 2018 were analyzed in the study.They were distributed into control group(seven cases)and experimental group(eight cases).Traditional cross positioning method under X-ray fluoroscopy was used in control group,and intraoperative ultrasound-guided precise puncture method was used in experimental group.Times of X-ray fluoroscopy,number of skin punctures,puncture time,intraoperative testing time,testing phase effective voltage,implantation position,postoperative evaluation period,stageⅡconversion rate,postoperative complications and postoperative voiding diary were analyzed in order to evaluate the clinical efficacy.Result:All the 15 procedures were successfully completed by the same surgeon.There was no significant difference in gender,age,BMI,sacral coccygeal vertebra morphological variation,urodynamics and other general data between the two groups.When comparing the control group and experimental group,the times of X-ray fluoroscopy,the number of skin punctures and the average puncture time showed significant difference(P<0.01);Also significant difference could be found in intraoperative testing time(P<0.05);Nevertheless,no significant difference was found in testing phase effective voltage,implantation position,postoperative evaluation period,stageⅡ conversion rate,postoperative incision exudate.Among the 15 patients,nine underwent stageⅡ procedure,no adverse event was detected during an average follow-up period of 6 months,and they were all satisfied with symptoms relief without recurrence.Conclusion:The application of intraoperative ultrasound-guided precise puncture methods remarkably reduced the times of X-ray fluoroscopy and number of skin punctures,and shorten the puncture time,improved the intraoperative testing efficacy,short-term follow-up indicated that ultrasound-guided puncture was safe and effective.Meanwhile,compared with the traditional methods,no postoperative complication was observed to increase.Looking forward to a further RCT study to verify the clinical effects of intraoperative ultrasound-guided precise puncture methods.
引文
1 THoen L A,Groen J,Scheepe J R,et al.Intermittent sacral neuromodulation for idiopathic urgency urinary incontinence in women[J].Neurourol Urodyn,2017,36(2):385-389.
2 Hoag N,Plagakis S,Pillay S,et al.Sacral neuromodulation for refractory overactive bladder after prior intravesical onabotulinumtoxinA treatment[J].Neurourol Urodyn,2017,36(5):1377-1381.
3 Maeda Y,OConnell P R,Lehur P A,et al.Sacral nerve stimulation for faecal incontinence and constipation:a European consensus statement[J].Colorectal Dis,2015,17(4):O74-O87.
4 Al-zahrani A A,Elzayat E A,Gajewski J B,et al.Longterm outcome and surgical interventions after sacral neuromodulation implant for lower urinary tract symptoms:14-year experience at 1center[J].J Urol,2011,185(3):981-986.
5 Matzel K E,Chartier-Kastler E,Knowles C H,et al.Sacral Neuromodulation:Standardized Electrode Placement Technique[J].Neuromodulation,2017,20(8):816-824.
6 李文成,石瑛,侯腾,等.PCNL术中超声引导穿刺有效性和安全性的肾盂造影对比研究[J].临床泌尿外科杂志,2017,32(6):418-421.
7 熊云鹤,宋超,林珍,等.术中实时超声监控在软性输尿管镜术治疗肾结石中的应用经验[J].临床泌尿外科杂志,2017,32(11):879-880,891.
8 Lin J A,Lu H T,Chen T L,et al.Ultrasound standard for lumbar plexus block[J].Br J Anaesth,2014,113(1):188-189.
9 Shakuri-Rad J,Cicic A,Thompson J.Prospective randomized study evaluating ultrasound versus fluoroscopy guided sacral InterStim(R)lead placement:A pilot study[J].Neurourol Urodyn,2018,37(5):1737-1743.
10 Zhang J,Zhang P,Wu L,et al.Application of an individualized and reassemblable 3Dprinting navigation template for accurate puncture during sacral neuromodulation[J].Neurourol Urodyn,2018.
11 顾寅珺,吕婷婷,方伟林,等.3D打印技术在骶神经调控术中精准穿刺的应用评估研究[J].临床泌尿外科杂志,2016,31(12):1057-1059,1063.
12 Cui Z,Wang Z,Ye G,et al.A novel three-dimensional printed guiding device for electrode implantation of sacral neuromodulation[J].Colorectal Dis,2018,20(1):O26-O29.
13 Ben-Ari A Y,Joshi R,Uskova A,et al.Ultrasound Localization of the Sacral Plexus Using a Parasacral Approach[J].Anesth Analg,2009,108(6):1977-1980.
14 罗莉,凌青,陈红.骶神经刺激器置入术的手术配合[J].中国保健营养,2018,28(11):235-236.
15 陈琦.超声引导S3骶神经定位装置及定位方法中国,CN201710520209.4[P].2017-11-21.
16 周惠芬,沈广澍,尹鑫,等.应用CT三维重建技术对290例骶后孔(八髎穴)变异性的研究[J].针刺研究,2016,41(4):361-364.
17 McGrath M C,Stringer M D.Bony landmarks in the sacral region:the posterior superior iliac spine and the second dorsal sacral foramina:a potential guide for sonography[J].Surg Radiol Anat,2011,33(3):279-286.
18 McCullough M C,Decker S,Ford J,et al.Third sacral foramina morphometry for sacral neuromodulation[J].Female Pelvic Med Reconstr Surg,2013,19(1):23-30.
2 Hoag N,Plagakis S,Pillay S,et al.Sacral neuromodulation for refractory overactive bladder after prior intravesical onabotulinumtoxinA treatment[J].Neurourol Urodyn,2017,36(5):1377-1381.
3 Maeda Y,OConnell P R,Lehur P A,et al.Sacral nerve stimulation for faecal incontinence and constipation:a European consensus statement[J].Colorectal Dis,2015,17(4):O74-O87.
4 Al-zahrani A A,Elzayat E A,Gajewski J B,et al.Longterm outcome and surgical interventions after sacral neuromodulation implant for lower urinary tract symptoms:14-year experience at 1center[J].J Urol,2011,185(3):981-986.
5 Matzel K E,Chartier-Kastler E,Knowles C H,et al.Sacral Neuromodulation:Standardized Electrode Placement Technique[J].Neuromodulation,2017,20(8):816-824.
6 李文成,石瑛,侯腾,等.PCNL术中超声引导穿刺有效性和安全性的肾盂造影对比研究[J].临床泌尿外科杂志,2017,32(6):418-421.
7 熊云鹤,宋超,林珍,等.术中实时超声监控在软性输尿管镜术治疗肾结石中的应用经验[J].临床泌尿外科杂志,2017,32(11):879-880,891.
8 Lin J A,Lu H T,Chen T L,et al.Ultrasound standard for lumbar plexus block[J].Br J Anaesth,2014,113(1):188-189.
9 Shakuri-Rad J,Cicic A,Thompson J.Prospective randomized study evaluating ultrasound versus fluoroscopy guided sacral InterStim(R)lead placement:A pilot study[J].Neurourol Urodyn,2018,37(5):1737-1743.
10 Zhang J,Zhang P,Wu L,et al.Application of an individualized and reassemblable 3Dprinting navigation template for accurate puncture during sacral neuromodulation[J].Neurourol Urodyn,2018.
11 顾寅珺,吕婷婷,方伟林,等.3D打印技术在骶神经调控术中精准穿刺的应用评估研究[J].临床泌尿外科杂志,2016,31(12):1057-1059,1063.
12 Cui Z,Wang Z,Ye G,et al.A novel three-dimensional printed guiding device for electrode implantation of sacral neuromodulation[J].Colorectal Dis,2018,20(1):O26-O29.
13 Ben-Ari A Y,Joshi R,Uskova A,et al.Ultrasound Localization of the Sacral Plexus Using a Parasacral Approach[J].Anesth Analg,2009,108(6):1977-1980.
14 罗莉,凌青,陈红.骶神经刺激器置入术的手术配合[J].中国保健营养,2018,28(11):235-236.
15 陈琦.超声引导S3骶神经定位装置及定位方法中国,CN201710520209.4[P].2017-11-21.
16 周惠芬,沈广澍,尹鑫,等.应用CT三维重建技术对290例骶后孔(八髎穴)变异性的研究[J].针刺研究,2016,41(4):361-364.
17 McGrath M C,Stringer M D.Bony landmarks in the sacral region:the posterior superior iliac spine and the second dorsal sacral foramina:a potential guide for sonography[J].Surg Radiol Anat,2011,33(3):279-286.
18 McCullough M C,Decker S,Ford J,et al.Third sacral foramina morphometry for sacral neuromodulation[J].Female Pelvic Med Reconstr Surg,2013,19(1):23-30.