Performing Radical Cystectomy and Urinary Diversion in Regional Anesthesia: Potential Risk Reduction in the Treatment of Bladder Cancer

Abstract

Objective: To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA), avoiding the adverse effects of general anesthesia. Materials and Methods: In our hospital, radical cystectomy with extended pelvic and iliac lymphadenectomy and urinary diversion was performed on 28 patients using CSTEA without applying general anesthesia, in 2011 and 2012. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Outcome measurements included operative time, blood loss, start of oral nutrition, start of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), postoperative complications according to the Clavien-Dindo classification and length of hospital stay. Results: All surgical procedures were performed without any complications and caused no anesthesiologically or surgically untoward effects. We observed no more severe complications than grade 1 according to the Clavien-Dindo classification. Conclusions: Our data show that CSTEA is an effective and safe technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks, especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes and complications of CSTEA.

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

“…The PubMed search for publications reporting on the same procedure identified three further studies. 8 – 10 Two of these studies reported on series including more than 10 individuals. 8 , 9 Of these, Friedrich-Freksa et al.…”

“… 8 – 10 Two of these studies reported on series including more than 10 individuals. 8 , 9 Of these, Friedrich-Freksa et al. 8 reported on a prospective series, whereas Tzortzis et al.…”

“… 8 , 9 Of these, Friedrich-Freksa et al. 8 reported on a prospective series, whereas Tzortzis et al. 9 described their experiences retrospectively.…”

“… 14 Those findings are supported by other previously published reports. 8 – 10 In the future, the incidence of urological malignancies in Germany has been predicted to rise. 15 In addition, the need for anaesthesiological alternatives to general anaesthesia for tumour ablative surgical procedures such as radical cystectomy is likely to increase, particularly in an ageing patient population with comorbidities.…”

“… 7 For patients with reduced performance status, relevant co-morbidities or advanced age, radical cystectomy using local or exclusive spinal and/or epidural anaesthesia has been described by several groups. 8 – 10 These case series have reported on the feasibility of this method and have described the benefits relevant for patient outcomes. In the present study, experience with radical cystectomy using local or exclusive spinal/epidural anaesthesia at the University Hospital for Urology, Klinikum Oldenburg, Oldenburg, Germany, is reported and compared with existing published studies, and the method is classified according to the IDEAL criteria.…”