老年患者腹腔镜泌尿系肿瘤根治术后慢性疼痛的影响因素

doi:10.19723/j.issn.1671-167X.2023.05.012

摘要/Abstract

摘要：

目的: 探讨接受腹腔镜泌尿系肿瘤根治术的老年患者术后慢性疼痛(chronic post-surgical pain，CPSP)发生率及影响因素。方法: 回顾性分析2021年10月至2022年3月在北京大学第三医院因泌尿系肿瘤行腹腔镜根治手术的65岁以上老年患者资料，在术后6个月时进行电话随访，统计CPSP的发生情况。根据国际疼痛学会(International Association for the Study of Pain，IASP)的诊断标准界定CPSP：(1)术后出现或强度增加的疼痛，且持续至少3个月；(2)疼痛可能不仅局限于原手术部位，有可能投射到支配该区的神经所在的整个区域(例如深部躯体或内脏组织)；(3)必须首先排除其他原因，如急慢性感染、恶性肿瘤或手术前就存在的慢性疼痛等。根据患者术后是否出现慢性疼痛分为CPSP组和非CPSP组。将单因素分析中P < 0.1的变量或临床上认为对结局有显著影响的变量纳入多因素Logistic回归分析。结果: 研究期间共216例老年患者因泌尿系肿瘤接受腹腔镜根治手术，剔除资料不完整等患者后，182例患者纳入本研究，其中男性146例，女性36例，平均年龄(72.6±5.2)岁。术后6个月时，58例(31.9%)患者报告CPSP。多因素回归分析显示，患者年龄≥ 75岁[比值比(odds ratio，OR)= 0.29，95%可信区间(confidence interval，CI)：0.12~0.73，P = 0.008]是老年患者腹腔镜泌尿系肿瘤根治术后发生CPSP的保护性因素；与其他类型肿瘤相比，肾癌(OR = 3.68，95% CI：1.58~8.58，P = 0.003)是发生CPSP的危险因素，术后24 h中重度疼痛(OR = 2.57，95% CI：1.14~5.83，P = 0.024)也是其危险因素。结论: 年龄 < 75岁、诊断为肾癌、术后24 h中重度疼痛是老年患者接受腹腔镜泌尿系肿瘤根治术后发生CPSP的影响因素，应优化术后多模式镇痛策略以预防CPSP的发生。

关键词: 泌尿系肿瘤, 疼痛, 手术后, 慢性疼痛, 腹腔镜检查, 老年人

Abstract:

Objective: To investigate the incidence and potential influence factors that contribute to chronic post-surgical pain (CPSP) in elderly patients with urinary tract tumors who underwent laparoscopic procedures. Methods: A retrospective study was conducted to collect the clinical data of 182 elderly patients with urinary tract tumors who were ≥65 years and underwent laparoscopic surgery from October 2021 to March 2022 in Peking University Third Hospital. The patients'demographic information, medical history and the severity of postoperative pain were collected. Telephone follow-ups were made 6 months after surgery, and the patients' CPSP conditions were recorded. The diagnostic criteria of CPSP were referred to the definition made by the International Association for the Study of Pain (IASP): (1) Pain that developed or increased in intensity after surgical procedure and persisted for at least 3 months after surgery; (2) Pain that localized to the surgical field or projected to the innervation territory of a nerve situated around the surgical area; (3) Pain due to pre-existing pain conditions or infections and malignancy was excluded. The patients were divided into two groups based on CPSP diagnosis. Risk factors that predisposed the patients to CPSP were identified using univariate analysis. A multivariate Logistic regression model using back-forward method was designed, including both variables that significantly associated with CPSP in the univariate analysis (P < 0.1), and the variables that were considered to have significant clinical impact on the outcome. Results: Two hundred and sixteen patients with urinary tract tumors who had undergone laparoscopic surgery were included, of whom, 34 (15.7%) were excluded from the study. For the remaining 182 patients, the average age was (72.6±5.2) years, with 146 males and 36 females. The incidence of CPSP at the end of 6 months was 31.9% (58/182). Multiva-riate regression analysis revealed that age ≥75 years (OR=0.29, 95% CI: 0.12-0.73, P=0.008) was the protecting factors for postoperative chronic pain in the elderly patients with urinary tract tumors undergoing surgical treatment, while renal cancer (compared with other types of urinary tract tumors) (OR=3.68, 95% CI: 1.58-8.58, P=0.003), and the 24 h postoperative moderate to severe pain (OR=2.57, 95% CI: 1.14-5.83, P=0.024) were the independent risk factors affecting CPSP. Conclusion: Age < 75 years, renal cancer and the 24 h postoperative moderate to severe pain are influence factors of the occurrence of CPSP after laparoscopic surgery in elderly patients with urinary tract tumors. Optimum postoperative multimodal analgesia strategies are suggested to prevent the occurrence of CPSP.

Key words: Urologic neoplasms, Pain, postoperative, Chronic pain, Laparoscopy, Aged

中图分类号:

R441.1

刘慧丽,吕彦函,王晓晓,李民. 老年患者腹腔镜泌尿系肿瘤根治术后慢性疼痛的影响因素[J]. 北京大学学报（医学版）, 2023, 55(5): 851-856.

Hui-li LIU,Yan-han LV,Xiao-xiao WANG,Min LI. Factors influencing the chronic post-surgical pain after laparoscopic surgery for elderly patients with urinary tract tumors[J]. Journal of Peking University (Health Sciences), 2023, 55(5): 851-856.

图/表 2

表1

表2

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Variables	Non-CPSP (n=124)	CPSP (n=58)	χ²	P
Gender			1.811	0.178
Male	103 (83.1)	43 (74.1)
Female	21 (16.9)	15 (25.9)
Age			6.623	0.010
65-74 years old	65 (52.4)	43 (74.1)
≥75 years old	59 (47.6)	15 (25.9)
Body mass index>24 kg/m²	71 (57.3)	27 (46.6)	0.125	0.723
ASA grade			0.716	0.699
Ⅰ	15 (12.1)	5 (8.6)
Ⅱ	78 (62.9)	39 (67.3)
Ⅲ	31 (25.0)	14 (24.1)
Diagnosis			12.005	0.017
Renal cancer	26 (21.0)	27 (46.6)
Bladder cancer	13 (10.5)	6 (10.3)
Renal pelvis cancer	8 (6.5)	2 (3.4)
Prostatic cancer	62 (50.0)	21 (36.2)
Ureteral cancer	15 (12.0)	2 (3.4)
Comorbidities
Hypertension	52 (41.9)	28 (48.3)	0.489	0.484
Diabetes	19 (15.3)	15 (25.9)	2.761	0.097
Cardiovascular disease	27 (21.8)	10 (17.2)	0.235	0.268
Cerebrovascular disease	10 (8.1)	8 (13.8)	1.479	0.224
Past history
History of surgery	65 (52.4)	32 (55.2)	0.184	0.668
History of smoking	38 (30.6)	20 (34.5)	0.236	0.627
History of drinking	21 (16.9)	13 (22.4)	0.573	0.449
Chronic preoperative pain	34 (27.4)	25 (43.1)	5.763	0.016
Peripheral nerve block	43 (34.7)	15 (25.9)	1.405	0.236
Patient controlled intravenous analgesia	52 (41.9)	22 (37.9)	0.042	0.837
Moderate to severe pain within 24 h postoperatively	58 (46.8)	37 (63.8)	3.707	0.054
Duration of surgery>2 h	87 (70.2)	36 (62.1)	1.018	0.313
Blood loss>100 mL	36 (29.0)	8 (13.8)	3.628	0.057
Admission to ICU	15 (12.1)	5 (8.6)	0.464	0.496
Length of hospital stay>8 d	57 (46.0)	23 (40.0)	0.403	0.526

Variables	OR	95% CI	P
Age≥75 years	0.29	0.12-0.73	0.008
Renal cancer^*	3.68	1.58-8.58	0.003
Diabetes	2.03	0.74-5.58	0.169
Blood loss>100 mL	1.43	0.51-1.56	0.111
Chronic preoperative pain	2.08	0.87-5.39	0.073
Moderate to severe pain within 24 h postoperatively	2.57	1.14-5.83	0.024