Grosso Paolo, D'Urso Leonardo, Collura Devis, Citro Raffaella, Grassano Maria Teresa, Macchiarulo Rosanna, Rivalta Luca, Valz Cristina, Muto Giovanni, Guglielmotti Enrica
S.C. Anestesia A, Presidio Ospedaliero S. Giovanni Bosco ASL 4 - Torino.
Arch Ital Urol Androl. 2009 Mar;81(1):13-6.
The management of Prostate cancer (PC), since PSA testing has been introduced in the clinical practice, has been significantly spoiled by a "leading-time bias" effect. As a consequence, this has brought to a dramatic diagnosis anticipation at the 4th-5th decade of life in sexually active and otherwise asymptomatic men. Standard options as radical prostatectomy or EBRT are hampered by a significant negative impact on patient's QoL. More recently several alternative minimally-invasive ablative treatment modalities have been proposed with promising results. Among these, TR-HIFU (Trans-Rectal High Intensity Focused Ultrasound) is playing a growing role in the treatment of localized low-intermediate risk PC, although long-term oncologic outcome are still awaited. In order to achieve an optimal result, a specific TR-HIFU's requirement is given by an unchanging target throughout the whole procedure. Therefore, the ideal anaesthesia should be either minimally-invasive and allow to get a motionless target up to 3-4 hours. A retrospective evaluation of efficacy and safety of a spinal anaesthesia in this patient's setting was done.
107 patients with localized prostate cancer treated in our institution from October 2004 to December 2007 with TR-HIFU procedure received a subarachnoidal anaesthesia with combined administration of 0.5% normobaric racemic bupivacaine (15 to 17.5 mg) and sufentanil 5 microg.
This technique allowed covering the whole TR-HIFU procedure (analgesia and motor blockade up to 4-5 hours). It was well tolerated by patients who only rarely required additional sedative or analgesics. A low anaesthesia-related side effects rate, as arterial hypotension, nausea and vomiting, and no severe side effects of intrathecal opioids, as deep sedation, bradycardia, myosis, bradypnea and oxygen desaturation, occurred. Intraoperative employment of sedatives and postoperative need of analgesics was low.
Using a low-dose intrathecal sufentanil an effective spinal block either on the sensitive and motor pathways was provided. Patients' tolerance to the procedure was good and the side-effect rate low. No adverse reactions to intrathecal sufentanil 5 microg were observed. In our experience TR-HIFU can be performed with neuraxial block in most of the cases and it's associated to a favorable cost-benefit rate.
自从前列腺特异性抗原（PSA）检测应用于临床实践以来，前列腺癌（PC）的治疗受到“领先时间偏倚”效应的显著影响。结果，这导致性活跃且无症状的男性在40至50岁时被提前诊断。根治性前列腺切除术或体外放射治疗（EBRT）等标准治疗方法对患者的生活质量有显著负面影响。最近，人们提出了几种替代性的微创消融治疗方式，并取得了有前景的结果。其中，经直肠高强度聚焦超声（TR-HIFU）在局限性低中危前列腺癌的治疗中发挥着越来越重要的作用，尽管其长期肿瘤学结果仍有待观察。为了获得最佳效果，整个手术过程中需要一个固定的靶点，这是TR-HIFU的一个特殊要求。因此，理想的麻醉应该是微创的，并且能使靶点在3至4小时内保持不动。我们对蛛网膜下腔麻醉在该患者群体中的有效性和安全性进行了回顾性评估。
2004年10月至2007年12月期间，在我们机构接受TR-HIFU治疗的107例局限性前列腺癌患者接受了蛛网膜下腔麻醉，联合使用0.5%等比重消旋布比卡因（15至17.5毫克）和舒芬太尼5微克。
该技术能够覆盖整个TR-HIFU手术过程（镇痛和运动阻滞长达4至5小时）。患者耐受性良好，很少需要额外的镇静剂或镇痛药。麻醉相关的副作用发生率较低，如动脉低血压、恶心和呕吐，且未出现鞘内阿片类药物的严重副作用，如深度镇静、心动过缓、瞳孔缩小、呼吸过缓和氧饱和度下降。术中镇静剂的使用和术后镇痛药的需求较少。
使用低剂量鞘内舒芬太尼可在感觉和运动通路上提供有效的脊髓阻滞。患者对手术的耐受性良好，副作用发生率较低。未观察到对5微克鞘内舒芬太尼的不良反应。根据我们的经验，大多数情况下TR-HIFU手术可以在神经轴阻滞下进行，且成本效益比良好。
