Trans Rectal Ultrasound Guided Injection Of Bladder Tumour Allowing Local Anaesthetic Resection In A High Risk Patient

摘要

Bladder cancer affects an elderly potentially unfit population. Low grade superficial disease confers an excellent prognosis following local resection assuming the patient can medically tolerate the procedure. We report a case where transrectal ultrasound guided local anaesthetic needle injection was used to safely allow rigid transurethral resection of a superficial tumour affecting the bladder base in a high risk patient deemed medically unfit for general or spinal anaesthetic. Introduction There are more than 10,000 people diagnosed with bladder cancer each year in the UK accounting for the fourth and tenth commonest malignancies in men and women respectively (http://www.cancerhelp.co.uk). The 1999 American Urological Association Guidelines on Bladder Cancer state that unless there is a medical contraindication, all visible bladder tumours should be removed (Smith et al., 1999). The initial tumour must be removed and subjected to histologic pathological review to determine the grade and stage. There are several acceptable methods that include transurethral resection, or combined with biopsy fulguration, cauterization, and laser vaporization.The incidence of bladder cancer increases with age and is associated with smoking which confers additional risks for both cardiac and respiratory co-morbidity in the affected population. As such a proportion of patients will have significant peri-operative mortality risk for what ultimately may prove to be low grade disease that is unlikely to progress (Solway, 2006). Previous reports have suggested the use of intravesical local anaesthetic in the outpatient management of patients with a known diagnosis of bladder cancer (Hedelin et al., 1997). We report the first case where a presumed diagnosis of bladder cancer in a patient deemed unfit for either general or spinal anaesthesia was treated successfully by transrectal ultrasound guided needle injection of local anaesthetic combined with rigid transurethral resection. Case Presentation and Management A 78 male presented via his general practitioner having been referred with a short history of painless frank haematuria on a background of severe chronic obstructive airways disease. He was seen urgently for a flexible cystoscopy and found to have an approximate 5cm diameter flat lesion affecting his right side and bladder base (figure 1) consistent with a clinical diagnosis of a bladder tumour (an ultrasound examination of his upper tracts was reported as normal).