Impact of neuraxial analgesia on outcomes following radical cystectomy: A systematic review

• Published in: Urologic oncology 2021-02, Vol.39 (2), p.100-108
• Main Authors: Rahman, Syed N., Cao, Daniel J., Flores, Viktor X., Monaghan, Thomas F., Weiss, Jeffrey P., McNeil, Brian K., Lazar, Jason M., Dimaculangan, Dennis, Winer, Andrew G.
• Format: Article
• Language: English
• Subjects: Complication; Epidural; Neuraxial; Radical cystectomy
• ISSN: 1078-1439; 1873-2496
• DOI: 10.1016/j.urolonc.2020.10.073

•Existing literature demonstrates a higher percentage of postoperative complications in patients receiving neuraxial analgesia following radical cystectomy.•No clear benefit was observed regarding neuraxial analgesia and a shortened hospital length of stay.•The impact of neuraxial analgesia on postoperative pain control following radical cystectomy is highly variable throughout the postoperative course.•No clear associations with neuraxial analgesia and long-term oncologic outcomes were observed. Radical cystectomy (RC) is associated with significant morbidity. Neuraxial analgesia is recommended by enhanced recovery after surgery guidelines, but largely supported by evidence extrapolated from colorectal surgery outcomes. We synthesized current evidence regarding short- and long-term outcomes associated with neuraxial analgesia versus patient controlled non-neuraxial analgesia following RC. PubMed, Embase, and Cochrane databases were searched for relevant studies published up to May 2020. Studies reporting complications, length of stay (LOS), pain score, opioid usage within 72 hours, overall survival, cancer-specific survival, and recurrence rate were included. Of 550 identified studies, 9 met criteria for inclusion. Four studies demonstrated a higher percentage of 90-day complications in the neuraxial analgesia cohort. Out of 6 studies reporting information regarding LOS, 4 demonstrated no improvement in LOS in the neuraxial cohort. A reduction in 72 hours post-RC opioid usage was observed in 2 out of 3 studies with available data. Information regarding post-RC pain scores were variable up to 3 days post-RC. One out of 2 studies with available data reported a significant association between neuraxial analgesia and an earlier time to recurrence. No significant associations were seen with respect to overall survival or cancer-specific survival. A majority of low-to-moderate quality evidence demonstrates neuraxial analgesia is associated with a higher rate of complications, variable information regarding pain control, no improvements in LOS, and no significant association with long-term oncological outcomes. Further research regarding the incorporation of nonopiate-based analgesic modalities into RC ERAS protocols is warranted.