Feasibility and safety of radical cystectomy under combined spinal and epidural anesthesia in octogenarian patients with ASA score ≥3: A case series

Combined spinal and epidural anaesthesia for open radical cystectomy: A controlled study

Objectives

To evaluate the feasibility of loco-regional anaesthesia and to compare perioperative outcomes between loco-regional and standard general anaesthesia in patients with bladder cancer undergoing open radical cystectomy (ORC).

Patients and Methods

A single-surgeon cohort of 60 consecutive patients with bladder cancer undergoing ORC with an enhanced recovery after surgery protocol between May 2020 and December 2021 was analysed. A study group of 15 patients operated on under combined spinal and epidural anaesthesia was compared with a control group of 45 patients receiving standard general anaesthesia. Intraoperative outcomes were haemodynamic stability, estimated blood loss, intraoperative red blood cell transfusion rate, and anaesthesia time. Postoperative outcomes were pain assessment 24 h after surgery, time to mobilisation, return to oral diet, time to bowel function recovery, length of stay and rate of 90-day complications.

Results

No patients required conversion from loco-regional to general anaesthesia. All patients in both groups were haemodynamically stable. No significant differences between groups were observed for all other intraoperative outcomes, except for a shorter anaesthesia time in the study versus control group (250 vs. 290 min, p = 0.01). Pain visual score 24 h after surgery was significantly lower in the study versus control group (0 vs. 2, p < 0.001). No significant differences were observed for all other postoperative outcomes, with a comparable time to bowel function recovery (5 days in each group for stool passage), and 90-day complication rate (46.6% vs. 42.2% for the study vs. control group, p = 0.76).

Conclusion

Our exploratory, controlled study confirmed the feasibility, safety and effectiveness of a pure loco-regional anaesthesia in patients with bladder cancer undergoing ORC. No significant differences were observed in intra- and postoperative outcomes between loco-regional and general anaesthesia, except for a significantly shorter anaesthesia time and greater pain reduction in the early postoperative period for the former.

Retrospective analysis of a surgical innovation using the IDEAL framework: radical cystectomy with epidural anaesthesia

Objectives

To retrospectively analyse experience of radical cystectomy using spinal/epidural anaesthesia and to classify this method using the IDEAL criteria.

Methods

Data from patients who had undergone radical cystectomy using spinal/epidural anaesthesia were evaluated retrospectively, focusing on clinical data, intraoperative and perioperative parameters and postoperative complications. Current literature reporting on this technique was reviewed and, together with the present study, evaluated according to the IDEAL recommendations.

Results

Three male patients aged 66–79 years who had undergone radical cystectomy with epidural anaesthesia were identified. The operating time ranged from 159–261 min and only minor complications occurred. Between 2013 and 2015, three published studies reported experiences with radical cystectomy with epidural/spinal anaesthesia; one was prospective and two were retrospective in nature and they included a total of 55 patients. According to the IDEAL classification, the present study corresponds to stage 1 (idea) and overall the surgical technique can be ranked as stage 2a (development).

Conclusions

Radical cystectomy with epidural anaesthesia is feasible and applicable for those who are not fit for general anaesthesia. The present study confirmed the functional results of this technique, which can be classified as IDEAL stage 2a on the basis of published studies.

How to lower postoperative complications after radical cystectomy - a review

Introduction

Lowering morbidity and mortality after RC is subject of considerable interest. Lately, many evidence-based data on improvements in operative technique, anesthetic management, and patient care have been published.

In this article, we present a review of literature on how to lower postoperative complications after RC.

Material and methods

The Medline, and Web of Science databases were searched without a time limit on February 2016 using the terms ‘cystectomy’ in conjunction with ‘radical’, ‘bladder cancer’, ‘complications’ or ‘management’. Boolean operators (NOT, AND, OR) were also used in succession to narrow and broaden the search. The search was limited to the English, Polish and Spanish literature.

Results

Many complications may be avoided by appropriate patient selection and meticulous introduction of care protocols.

Conclusions

RC as treatment free of complications, even in the hands of an experienced urologist, does not exist. A large number of complications are acceptable in the name of good long-term results. Optimum results are possible with proper surgical technique, good patients and urinary diversion selection and proper patient management in the pre-, peri, and postoperative period.