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

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

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Abstract

© 2018 The Author(s). 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.
Original languageEnglish
Article number157
JournalAnesthesiology
Volume18
DOIs
Publication statusPublished - 3 Nov 2018

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Epidural Anesthesia
Urinary Bladder Neoplasms
Tertiary Care Centers
Cohort Studies
Sufentanil
Neoplasms
General Anesthesia
Morphine
Anesthetics
Recurrence
Cystectomy
Survival
Propensity Score
Perioperative Period
Epidural Analgesia
Conduction Anesthesia
Proportional Hazards Models
Disease-Free Survival
Analgesics
Urinary Bladder

Keywords

  • Cystectomy
  • Epidural anesthesia
  • Perioperative period
  • Retrospective review

Cite this

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

In: Anesthesiology, Vol. 18, 157, 03.11.2018.

Research output: Contribution to journalArticle

Chipollini, Juan ; Alford, Brandon ; Boulware, David C. ; Forget, Patrice ; Gilbert, Scott M. ; Lockhart, Jorge L. ; Pow-Sang, Julio M. ; Sexton, Wade J. ; Spiess, Philippe E. ; Poch, Michael A. ; Patel, Sephalie Y. / 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 . In: Anesthesiology. 2018 ; Vol. 18.
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title = "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 = "{\circledC} 2018 The Author(s). 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.",
keywords = "Cystectomy, Epidural anesthesia, Perioperative period, Retrospective review",
author = "Juan Chipollini and Brandon Alford and Boulware, {David C.} and Patrice Forget and Gilbert, {Scott M.} and Lockhart, {Jorge L.} and Pow-Sang, {Julio M.} and Sexton, {Wade J.} and Spiess, {Philippe E.} and Poch, {Michael A.} and Patel, {Sephalie Y.}",
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T1 - Epidural anesthesia and cancer outcomes in bladder cancer patients

T2 - is it the technique or the medication? A matched-cohort analysis from a tertiary referral center

AU - Chipollini, Juan

AU - Alford, Brandon

AU - Boulware, David C.

AU - Forget, Patrice

AU - Gilbert, Scott M.

AU - Lockhart, Jorge L.

AU - Pow-Sang, Julio M.

AU - Sexton, Wade J.

AU - Spiess, Philippe E.

AU - Poch, Michael A.

AU - Patel, Sephalie Y.

PY - 2018/11/3

Y1 - 2018/11/3

N2 - © 2018 The Author(s). 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.

AB - © 2018 The Author(s). 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.

KW - Cystectomy

KW - Epidural anesthesia

KW - Perioperative period

KW - Retrospective review

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U2 - 10.1186/s12871-018-0622-5

DO - 10.1186/s12871-018-0622-5

M3 - Article

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JO - Anesthesiology

JF - Anesthesiology

SN - 0003-3022

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