Neuraxial anesthesia versus general anesthesia for urological surgery: systematic review

Number of transurethral procedures after non-muscle-invasive bladder cancer and survival in causes other than bladder cancer

Background

Previous research has associated repeated transurethral procedures after a diagnosis of non-muscle invasive bladder cancer (NMIBC) with increased risk of death of causes other than bladder cancer.

Aim

We investigated the overall and disease-specific risk of death in patients with NMIBC compared to a background population sample.

Methods

We utilized the database BladderBaSe 2.0 containing tumor-specific, health-related and socio-demographic information for 38,547 patients with NMIBC not primarily treated with radical cystectomy and 192,733 individuals in a comparison cohort, matched on age, gender, and county of residence. The cohorts were compared using Kaplan-Meier curves and Hazard ratios (HR) from a Cox regression models. In the NMIBC cohort, we analyzed the association between number of transurethral procedures and death conditioned on surviving two or five years.

Results

Overall survival and survival from causes other than bladder cancer estimated with Kaplan-Meier curves was 9.3% (95% confidence interval (CI) (8.6%-10.0%)) and 1.4% (95% CI 0.7%-2.1%) lower respectively for the NMIBC cohort compared to the comparison cohort at ten years. In a Cox model adjusted for prognostic group, educational level and comorbidity, the HR was 1.03 (95% CI 1.01–1.05) for death from causes other than bladder cancer comparing the NMIBC cohort to the comparison cohort. Among the NMIBC patients, there was no discernible association between number of transurethral procedures and deaths of causes other than bladder cancer after adjustment. The number of procedures were, however, associated with risk of dying from bladder cancer HR 3.56 (95% CI 3.43–3.68) for four or more resections versus one within two years of follow-up.

Conclusion

The results indicate that repeated diagnostic or therapeutic transurethral procedures under follow-up do not increase of risk dying from causes other than bladder cancer. The modestly raised risk for NMIBC patients dying from causes other than bladder cancer is likely explained by residual confounding.

Modern Lower Extremity Bypass Outcomes by Anesthesia Type in the Veteran Population

BACKGROUND

Lower extremity bypass (LEB) revascularization can be performed under general (GA) or neuraxial anesthesia (NA). Studies show that the use of NA may decrease morbidity, 30-day mortality, and hospital length-of-stay (LOS). The goal of our analysis is to examine the differences in postsurgical outcomes following LEB between patients who undergo GA compared to NA in the Veteran Affairs Surgical Quality Improvement Program (VASQIP) database.

METHODS

After IRB approval, the VASQIP database was assessed for patients who underwent LEB between 1998-2018. Only infrainguinal bypass procedures and anesthesia type classified as "general," "epidural," or "spinal" were included. The neuraxial cohort includes both spinal and epidural anesthesia patients. The Risk Analysis Index (RAI), a validated measure of frailty, was additionally calculated for each patient. Chi squared, paired t-test, and binary logistic regression were used to compare the cohorts.

RESULTS

During this period, 22,960 veterans underwent LEB recorded in VASQIP. Compared to those who underwent surgery under GA, patients with procedures performed using NA were older (66.4 ± 9.6 years vs. 65.3 ± 9 years respectively; P <0.001) and more frail (average RAI score 25.7 ± 7.0 vs. 24.9 ± 6.7; P < 0.001). Operative time was shorter in the NA group (4.1 ± 1.7 hrs vs. 4.7 ± 3.0 hrs; P < 0.001) and fewer cases were emergent (1.55% vs. 4.13%; P <0.001). Patients in the GA group had higher rates of postoperative prolonged ileus (0.31% vs. 0.00%; P = 0.03), pneumonia (1.60% vs. 1.06%; P = 0.025), deep wound infection (2.67% vs. 2.61%; P = 0.01), sepsis (1.68% vs. 0.79%; P < 0.001), reintubation (1.80% vs. 1.30%) (P = 0.04),and number of packed red blood cell (pRBC) transfused intraoperatively (0.39 ± 1.21 units vs. 0.22 ± 0.79 units; P <0.001). There was no significant difference in rate of graft failure, return to the OR, myocardial infarction, death, or LOS. In regression analysis, those undergoing NA were less likely to require pRBC transfusion intraoperatively (OR: 0.43; 95% CI: 0.31-0.61; P < 0.001), however no other outcomes reached statistical significance.

CONCLUSION

Although younger and less frail, veteran patients undergoing GA for lower extremity revascularization had higher rates of postoperative ileus, pneumonia, deep wound infection, sepsis, and need for transfusion as compared to those undergoing NA. There was no significant difference in the rate of other major complications, myocardial infarction, death or LOS. After adjustment, only intraoperative transfusion remained statistically significant, likely reflecting longer and more complex cases for those that undergo general anesthesia rather than the effect of anesthetic choice itself.

Impact of epidural bupivacaine on perioperative opioid requirements, recovery characteristics, and duration of hospitalization in dogs undergoing cystotomy: A retrospective study of 56 cases

OBJECTIVE

To compare perioperative opioid consumption and duration of hospitalization (DOH) in anesthetized dogs receiving opioid-based analgesia (OBA) vs those receiving bupivacaine epidural-based analgesia (EPID) during cystotomy.

STUDY DESIGN

Retrospective cross-sectional study.

ANIMALS

Fifty-six client-owned dogs undergoing cystotomy.

METHODS

Clinical records of dogs undergoing cystotomy between January 2015 and December 2017 were reviewed. Demographic data, duration of anesthesia and surgery, anesthetic management, perioperative opioid consumption expressed in morphine equivalents (ME), perioperative use of adjuvant analgesics, time to first micturition, time to eat, time to ambulate, and DOH were recorded. Opioid consumption and DOH were compared with a Wilcoxon rank-sum test, followed by linear regression analysis as appropriate. Time to first micturition, time to eat, and time to walk unassisted were modeled with Cox-proportional hazard models.

RESULTS

Dogs treated with EPID during surgery required 1.5 mg/kg ME less compared with those treated with OBA (P = .04) during surgery. Three of 19 dogs treated with EPID vs 15 of 37 dogs receiving OBA required intraoperative adjuvant analgesics (P = .06). Dogs treated with EPID regained motor function slower than dogs treated with OBA (P = .01); however, there was no difference in time to urinate, time to eat, or DOH between treatments.

CONCLUSION

Perioperative lumbosacral epidural with bupivacaine reduced intraoperative opioid consumption in dogs anesthetized for cystotomy.

CLINICAL SIGNIFICANCE

The use of epidural bupivacaine in dogs undergoing cystotomy may reduce intraoperative opioid requirements without affecting return of bladder function or DOH.

[Prevention and correction of cognitive dysfunction after general anesthesia]

AIM

To evaluate clinical efficacy of intraoperative use of cytoflavin in the prevention and correction of cognitive functions in surgical patients with no history of neurological and psychosomatic disorders.

MATERIAL AND METHODS

The study included 60 female patients who underwent surgery on the thyroid gland. Patients were stratified into two equal groups matched for main indices. Patients of the main group received infusions of cytoflavin (20 ml in 200 ml of 5% glucose solution). Patients underwent thyroidectomy with general inhalation anesthesia using desflurane. Cognitive testing was performed one day before operation and 6, 24 and 48 h after. Waking time after stopping desflurane administration and time prior tracheal extubation were recorded.

RESULTS AND CONCLUSION

The use of cytoflavin promoted the early post anesthesia adaptation and more rapid recovery of initial cognitive status of the patients.

Effect of different anesthetic methods on cellular immune functioning and the prognosis of patients with ovarian cancer undergoing oophorectomy

The present study aimed to explore the effects of different anesthetic methods on cellular immune function and prognosis of patients with ovarian cancer (OC) undergoing oophorectomy. A total of 167 patients who received general anesthesia (GA) treatment (GA group) and 154 patients who received combined general/epidural anesthesia (GEA) treatment (GEA group) were collected retrospectively. Each group selected 124 patients that met the inclusion and exclusion criteria for further study. ELISA and radioimmunoassay were employed to detect levels of IL-2, TNF-α, and CA-125. The rates of tumor-red cell rosette (RTRR), red cell immune complex rosette (RRICR), and red cell C3b receptor rosette (RRCR) were also measured. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were determined by hemodynamics. The levels of tumor necrosis factor-α (TNF-α) and interleukin (IL)-2 decreased at 1 h intraoperation (T2), but increased 24-h post surgery (T3). The levels of TNF-α and IL-2 were recovered faster in the GEA group than in the GA group. The GA group exhibited greater levels of CA-125 expression than in the GEA group. The levels of RTRR, RRICR, and RRCR; ratios of CD3⁺, CD4⁺, CD4⁺/CD8⁺, CD16⁺, and CD56⁺ at 30 min after anesthesia (T1), T2, T3 and 48 h after the operation (T4) and levels of SBP, DBP, and HR at T1, T2, and T3 displayed increased levels in the GEA group than in the GA group. At 72-h post surgery (T5), the 5-year survival rate significantly increased in the GEA group compared with the GA group. GEA to be more suitable than GA for surgery on OC patients.

Perioperative regional anaesthesia and postoperative longer-term outcomes

Regional anaesthesia provides effective anaesthesia and analgesia in the perioperative setting. Central neuraxial blocks-that is, spinal and epidural blocks-are well established as an alternative or adjunct to general anaesthesia. Peripheral blocks may be used as part of multimodal anaesthesia/analgesia in perioperative practice, reducing the need for opioid analgesics and enhancing early recovery. Furthermore, regional anaesthesia has increased in popularity and may be done with improved ease and safety with the introduction of ultrasound-guided techniques. The effects of local anaesthetics and regional anaesthesia on long-term outcomes such as morbidity, mortality, the quality of recovery beyond the duration of analgesia, and whether it can expedite the resumption of activities of daily living are less clear. It has also been suggested that regional anaesthesia may impact the risk of metastasis after cancer surgery. This article provides an overview of current evidence around quality of recovery, risk for delirium, long-term effects, and possible impact on cancer disease progression associated with the clinical use of local and regional anaesthetic techniques. In summary, there is still a lack of robust data that regional anaesthesia has a clinical impact beyond its well-acknowledged beneficial effects of reducing pain, reduced opioid consumption, and improved quality of early recovery. Further high-quality prospective studies on long-term outcomes are warranted.