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

Abstract

BackgroundThe 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.MethodsWe 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.ResultsOnly 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.ConclusionsEpidural 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.

Peridural Anesthesia and Cancer-Related Survival after Surgery for Pancreatic Cancer—A Retrospective Cohort Study

“…In contrast, no benefit of PDA on overall survival or cancer recurrence was found in patients with colorectal [48], prostatic [49] or bladder cancer [8,50]. Evaluating patients with major abdominal surgery for cancer, further studies [8,26,27,45] could not observe any significant influence of anaesthetic technique on patients' outcome, either.…”

“…In contrast, no benefit of PDA on overall survival or cancer recurrence was found in patients with colorectal [48], prostatic [49] or bladder cancer [8,50]. Evaluating patients with major abdominal surgery for cancer, further studies [8,26,27,45] could not observe any significant influence of anaesthetic technique on patients' outcome, either. Yet, in these collectives, the patients had various surgical procedures including gastrectomy, pancreatectomy, colectomy, hepatectomy, cystectomy, nephrectomy or prostatectomy.…”

“…Hereby, three factors of stress response are considered to impair cellular immunity: the response to surgical trauma, to general anesthesia, and to opioid analgesia [7]. Furthermore, general anesthesia itself is known to impair various immune components such as neutrophil, macrophage, dendritic cell, T-cell, and NK-cell functions [8][9][10][11][12]. In addition, opioids given during anesthesia and for postoperative pain control inhibit humoral and cellular immune response, natural killer cell activity, cytokine expression and phagocytic activity [12,13].…”

Positive Impact of Intraoperative Epidural Ropivacaine Infusion on Oncologic Outcomes in Pancreatic Cancer Patients Undergoing Pancreatectomy: A Retrospective Cohort Study

“…In recent years, the effect of intraoperative anesthetic management on long-term clinical outcome of cancer patients has become an interesting research topic. Several retrospective studies reported that local anesthesia, especially perioperative epidural analgesia, was related to better survival and a lower incidence of local recurrence or distant metastasis in cancer patients [5][6][7][18][19][20][21]. Tyler et al observed the association between use of epidural anesthesia during primary pancreatic cancer resection and improved survival among PDAC patients [9].…”

“…However, surgical intervention might impair cell-mediated immunity and activated circulating tumor cells implantation which leave patients susceptible to develop of postoperative recurrence or metastasis 3 , 4 . Multiple retrospective studies have shown that regional anesthesia improved patient outcome after surgery in bladder, breast and lung cancers 5 - 7 . In addition, regional anesthesia such as epidural anesthesia may blunt the pro-metastatic effect of surgical stress and inhibit tumor growth and metastasis, especially in high concentrations 8 .…”