The Study Of Clinical Application Of Percutaneous Nephrolithotomy Under Local Infiltration Anesthesia For High Risk Patients With Upper Urinary Tract Calculi

Background and objectiveThe continuous advancement of techniques and upgrade of equipment have contributed to the development of a new technique,percutaneous nephrolithotomy(PCNL)under local infiltration anesthesia(LIA).This technique has many advantages because of its mild effects on the respiratory and cardiovascular systems—patients has lower stress response,faster recovery and less hospitalization costs.At home and abroad,many studies about the feasibility and safety of PCNL under LIA have been published.However,most studies select patients with low surgical risk,which results in a selection bias.Some patients were excluded if they were diagnosed with high risk,such as elderly patients with severe comorbidity.There are a rare few of studies about surgical outcomes and postoperative complications of the patients under different risk levels.The American Society of Anesthesiologists(ASA)score,is used to assess operative risk of anesthesia and patients’ tolerance to various surgical manipulations.We stratified our patients according to the ASA scores and divided into a high-risk group(ASA=Ⅲ,Ⅳ)and a low-risk group(ASA=Ⅰ,Ⅱ).The surgical outcomes,postoperative complications and relevant clinical data between two groups were analyzed.The technique’s efficacy for patients under different Guy’s stone grades was also assessed.We aimed to explore the technique’s scope of clinical application and curative effect.In addition,We observed the intraoperative pain scores of all this series patients.As to apply this technique preferably,we tried to find the influence factors of intraoperative pain score.We made a correlation analysis between clinical data and intraoperative pain score.The significant correlation variables were incorporated into multiple regression analysis.MethodsWe evaluated a total of 232 patients with upper urinary tract calculi undergoing PCNL under LIA from 2017.11 to 2019.11 at Zhujiang Hospital.They were divided into high-risk group with ASA score Ⅲ or Ⅳ(n=58)and low-risk group with ASA scoreⅠ or Ⅱ(n=174).The Charlson comorbidity index(CCI)was used to predict the risk of patients’comorbidity while the Guy’s stone score was used to assess the calculus complexity and the extend of difficulty of the operation.All patients have completed Visual Analog Scale(VAS)questionnaires about intraoperative pain level and postoperative pain level after 6h and 24h of the operation.Together with other clinical data and surgical data,the data from VAS were collectively used for statistical analysis.ResultThe high-risk group had significantly more comorbidities than the low-risk group(2.53 vs 0.49,P<0.05).There were significant difference in ASA average score(3.25±0.06 vs 1.47±0.04),average age(63.09±1.71 vs 48.25±0.93years),and average CCI score(2.53±0.14 vs 0.49±0.05)between two groups.There were no significant differences in Guy’s stone score(1.98±0.15 vs 1.90±0.08,P>0.05),body mass index(BMI),and the stone’s distribution rate on different sides.But the occurrence rate of complex stone situation was higher in the high-risk group than in the low-risk group(36.2%vs 21.8%,P<0.05)The mean operative time in the high-risk group was significantly shorter than that that in the low-risk group(34.53± 1.30 vs 39.72±0.68min),and postoperative hospital stay in the high-risk group was significantly prolonged(6.53±0.40 vs 4.71±0.09 days)(P<0.05).Although the demand of blood transfusion in the high-risk group was significantly higher(8.6%vs 0.6%,P<0.05),the average reduction of hemoglobin(0.89±0.10 vs 0.85±0.04g/dL)and the overall occurrence rate of complication(17.2%vs9.8%)were similar between the high-risk and low-risk groups(P>0.05).There were no significant differences in the first phase stone clearance rate(77.6%vs 85.1%)between the two groups(P>0.05).Also,there were no significant difference in the first phase stone clearance rate of each Guy’s stone grade(Grade Ⅰ:96.2%vs96.3%,Grade Ⅱ:76.5%vs96.7%,Grade Ⅲ:60%vs59.9%,Grade Ⅳ:40%vs55.6%,P<0.05).The average VAS scores of intraoperative pain(3.83±0.12 vs 4.04±0.08)and postoperative pain after 6 hours and 24 hours of the operation(2.81 ±0.11 vs 2.86±0.06,2.05±0.08 vs 2.08±0.05)had no significant difference.The multiple regression analysis indicated that the main factors affecting the extend of intraoperative pain were age,gender,BMI,history of ESWL,stone burden,and operative time.ConclusionPCNL under LIA is a safe and feasible technique even for the high-risk patients.LIA can well satisfy the analgesic needs for PCNL without affecting the surgical efficacy and safety.This technique is suitable for patients in different kinds of ASA grades and Guy’s stone grades.Patients have good tolerance to the operation.LIA minimally affect patients’ physiological status and behavior so patients can get fast recovery after surgery.This technique reduce hospitalization time and costs,and save medical resources.It’s worthy of wide application and promotion.The results of multiple regression analysis show that age,gender,BMI,history of ESWL,stone burden,and operative time are major factors affecting the intraoperative pain intensity.