Journal Article

Epidural anesthesia and cancer outcomes in bladder cancer patients: is it the technique or the medication? A matched-cohort analysis from a tertiary referral center

Boulware, David C., Gilbert, Scott M., Patel, Sephalie Y., Chipollini, Juan, Sexton, Wade J., Lockhart, Jorge L., Alford, Brandon, Forget, Patrice, Spiess, Philippe E., Poch, Michael A., Pow-Sang, Julio M.

2018

Overview

Background The perioperative period can be a critical period with long-term implications on cancer-related outcomes. In this study, we evaluate the influence of regional anesthesia on cancer-specific outcomes in a radical cystectomy (RC) cohort of patients. Methods We performed a retrospective analysis of patients with clinically-nonmetastatic urothelial carcinoma of the bladder who underwent RC at our institution from 2008 to 2012. Patients were retrospectively registered and stratified based on two anesthetic techniques: perioperative epidural analgesia with general anesthesia (epidural) versus general anesthesia alone (GA). Epidural patients received a sufentanil-based regimen (median intraoperative sufentanil dose 50 mcg (45,85). Propensity-score was used to make 1:1 case-control matching. Cumulative risk of recurrence with competing risks was calculated based on anesthetic technique. Kaplan-Meier curves were used to compare recurrence-free (RFS) and cancer-specific survival (CSS). Univariable and multivariable analyses were performed with Cox proportional hazard regression models for RFS and CSS. Results Only patients with complete data on anesthetic technique were included. Out of 439 patients, 215-pair samples with complete follow-up were included in the analysis. Median follow-up was 41.4 months (range: 0.20–101). Patients with epidurals received higher median total intravenous morphine equivalents (ivMEQ) versus those in the GA group (75 (11–235) vs. 50 ivMEQ (7–277), p  < 0.0001). Cumulative risk of recurrence at two years was 25.2% (19.6, 31.2) for epidural patients vs. 20.0% (15.0, 25.7) for GA patients (Gray test p  = 0.0508). Epidural analgesic technique was a significant predictor of worse RFS (adjusted HR = 1.67, 1.14–2.45; p  = 0.009) and CSS (HR = 1.53, 1.04–2.25; p  = 0.030) on multivariable analyses. Conclusions Epidural anesthesia using sufentanil was associated with worse recurrence and disease-free survival in bladder cancer patients treated with surgery. This may be due use of epidural sufentanil or due to the increased total morphine equivalents patient received as a consequence of this drug.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Aged / Analgesia / Analgesics / Analysis / Anesthesia / Anesthesia, Epidural - methods / Anesthesia, General - methods / Anesthesiology / Angiogenesis / Bladder cancer / Bread puddings / Breast cancer / Carcinoma, Transitional Cell - pathology / Carcinoma, Transitional Cell - surgery / Case-Control Studies / Cohort analysis / Cohort Studies / Critical Care Medicine / Cystectomy / Cystectomy - methods / Disease-Free Survival / Emergency Medicine / Epidural anesthesia / Female / Follow-Up Studies / Gastric cancer / Humans / Intensive / Internal Medicine / Intravenous administration / Kaplan-Meier Estimate / Lung cancer / Male / Medicine / Medicine & Public Health / Metastasis / Methods / Middle Aged / Morphine / Morphine - administration & dosage / Narcotics / Neoplasm Recurrence, Local / Pain / Pain perception / Patients / Perioperative medicine and outcome / Perioperative period / Postoperative period / Propensity Score / Regression analysis / Research Article / Retrospective review / Retrospective Studies / Sufentanil / Surgery / Surveillance / Survival / Tertiary Care Centers / Urinary Bladder Neoplasms - pathology / Urinary Bladder Neoplasms - surgery / Urothelial carcinoma / Vascular endothelial growth factor