Association Between Anesthetic Technique and Survival After Radical Nephroureterectomy: A Propensity Score-matching Study

Abstract

Background/Aim: Whether anesthesia can affect oncological outcomes in urothelial carcinoma of the upper urinary tract undergoing radical nephroureterectomy (RNU) is not clear. Patients and Methods: One-hundred an ninetyseven patients who underwent RNU were retrospectively recruited and divided into total intravenous (TIVA, n=90) and volatile inhalation anesthesia (VIA, n=107) groups. A 1:1 propensity score-matching method was employed to minimize selection bias (n=70 each). Cancer-specific (CSS), overall (OS) and metastasis-free (MFS) survival were compared between groups before and after matching. Results: For all survival endpoints, no significant differences were observed between the two study groups, both before (hazard ratio for TIVA: CSS: 0.70, OS: 0.75, MFS: 0.78) and after (hazard ratios for TIV: CSS: 1.21, OS: 0.82, MFS: 0.84) matching. Conclusion: With no survival difference observed according to anesthetic technique for RNU, the choice should be based on factors such as accessibility, prevention of side-effects, or costs.With the growing number of cancer cases, the number of patients undergoing surgery under general anesthesia is also increasing (1). In recent years, hypotheses have emerged that the anesthetic technique during surgery may impact cancer recurrence or survival. Proposed mechanisms involve the characteristics of agents used in volatile inhalation anesthesia (VIA) and total intravenous anesthesia (TIVA). According to previous studies, VIA agents can impair immune function enabling tumor cells to evade natural killer cells (2) and can up-regulate signaling pathways such as the hypoxia-inducible factor 1-alpha (HIF1α) pathway, thereby promoting the proliferation of residual tumors (3). By contrast, propofol used in TIVA may protect from cancer recurrence through its antiinflammatory and antioxidant potentials (4, 5).However, the clinical evidence on this topic remains conflicting. Wigmore et al. reported based on a dataset of mixed malignancy types that the use of TIVA is associated with a lower overall risk of death compared to VIA (6). Several publications found similar results (7-9), but other studies showed no benefit of TIVA over VIA (10)(11)(12). For urothelial carcinoma (UC), Pfail et al. demonstrated that VIA is associated with an increased risk of recurrence compared to TIVA during robot-assisted radical cystectomy for bladder cancer (13). To date, there is no evidence whether the type of anesthetic technique impacts cancer recurrence or survival in patients with UC of the upper tract (UCUT) undergoing radical nephroureterectomy (RNU). As recurrences after RNU, especially in invasive cases, are not rare, understanding of this association is of clinical importance (14).In this context, we aimed to evaluate cancer recurrence and survival of patients by anesthetic type, utilizing propensity score matching to adjust patient characteristics and minimize preoperative selection bias. Patients and MethodsPatient selection and data collection. This retrospective study included 224 consecutiv...

Effects of anesthesia on long-term survival in cancer surgery: A systematic review and meta-analysis

“…Forty-two retrospective cohort studies and two RCTs with a total of 686,923 patients were included in this study [ [19] , [20] , [21] , [22] , [23] , [24] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] , [56] , [57] , [58] , [59] , [60] , [61] , [62] , [63] , [64] , [65] , [66] , [67] , [68] , [69] , [70] , [71] ]. Thirty-five trials were single-center studies [ 19 , [21] , [22] , [23] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [50] , [51] , …”

“…Types of cancer surgery and inhalation anesthetics varied between studies. In total, two studies enrolled participants undergoing surgery for glioblastoma [ 47 , 56 ], one study for oral cancer [ 63 ], nine studies for breast cancer [ 34 , 37 , 42 , 45 , 49 , 53 , 59 , 61 , 71 ], five studies for non-small cell lung cancer [ 38 , 55 , 60 , 65 , 69 ], two studies for esophageal cancer [ 36 , 68 ], four studies for gastric cancer [ 40 , 44 , 50 , 57 ], five studies for colorectal cancer [ 34 , 39 , 48 , 54 , 62 ], four studies for hepatobiliary cancer [ 19 , 41 , 43 , 51 ], two studies for pancreatic cancer [ 52 , 64 ], two studies for gynecological cancer [ 21 , 22 ], two studies for urological cancer [ 23 , 58 ], one study for osteosarcoma [ 66 ], and six studies for various cancers [ 20 , 24 , 35 , 46 , 68 , 70 ]. For inhalation anesthetics, seventeen studies used sevoflurane to maintain anesthesia [ 19 , 21 , 34 , 38 , 40 , [47] , [48] , [49] , 53 , 59 , [62] , [63] , [64] , …”

“…For inhalation anesthetics, seventeen studies used sevoflurane to maintain anesthesia [ 19 , 21 , 34 , 38 , 40 , [47] , [48] , [49] , 53 , 59 , [62] , [63] , [64] , [65] , 67 , 70 , 71 ], nine studies used desflurane [ 22 , 39 , [41] , [42] , [43] , 50 , 52 , 56 , 66 ] and eighteen studies administered various inhalation anesthetics [ 20 , 23 , 24 , [35] , [36] , [37] , [44] , [45] , [46] , 51 , 54 , 55 , 57 , 58 , 60 , 61 , 68 , 69 ]. Twenty-six studies included elective surgery [ 19 , 21 , 22 , 36 , [38] , [39] , [40] , [41] , 43 , 44 , [46] , [47] , [48] , [50] , [51] , [52] , [53] , 56 , 60 , [62] , [63] , …”

“…Previous systematic reviews and meta-analyses investigated the association between intravenous and inhalation anesthetics and long-term survival of cancer patients [ [15] , [16] , [17] , [18] ], however, the conclusions remained inconsistent with insufficient sizes. Subsequently, more studies have been published to address this controversy [ [19] , [20] , [21] , [22] , [23] , [24] ]. Therefore, we performed an updated systematic review and meta-analysis to investigate the effect of propofol-based anesthesia and inhalation anesthesia on long-term survival in patients undergoing cancer surgery.…”

Association of VolatileVersusIntravenous Anesthesia With Prognosis After Nephrectomy for Renal Cell Carcinoma

“…However, results among individual studies investigating the effect of anesthetic techniques in various types of cancers, were inconsistent. Although intravenous anesthesia has been associated with better outcomes in patients with esophageal (7), gastric (8), and colon cancers (9), no significant association between anesthesia type and long-term survival has been found in patients with breast (10,11), rectal (12), lung cancers (13), and urothelial carcinoma (14). This may suggest a differential effect of anesthetic agents on different cancer types.…”