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Table of Contents
Year : 2021  |  Volume : 32  |  Issue : 3  |  Page : 111-116

Feasibility and safety of retrograde radical cystectomy under combined spinal and epidural anesthesia in high-risk and elderly patients. A single surgeon experience

1 Department of Urology, SKIMS, Srinagar, JK, India
2 Department of Anaesthesiology, SKIMS, Srinagar, JK, India

Date of Submission23-Nov-2020
Date of Decision08-Feb-2021
Date of Acceptance17-Feb-2021
Date of Web Publication28-Sep-2021

Correspondence Address:
Abdul Rouf Khawaja
Department of Urology, SKIMS, Soura Srinagar Kashmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_156_20

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Purpose: The purpose of the study is to study feasibility and safety of retrograde radical cystectomy (RC) under regional anesthesia (RA) in high-risk and elderly patients of muscle invasive bladder carcinoma. Materials and Methods: This study was an observational study, conducted in the department of urology, SKIMS, Kashmir, India, from 2012 to 2020. All patients underwent retrograde RC under RA. Results: Thirty-seven patients were operated with median follow-up period of 32 months and included 30 male and 7 female patients with median age of 74.5 years (70–83 years). The American Society of Anesthesiologists score was II in 20 patients, III in 15 patients, and IV in 2 patients. All the patients included in study had significant comorbidities. All patients were anemic and required preoperative blood transfusions for optimization. Total blood loss ranged from 200 to 900 ml (mean: 400 ml). Bilateral internal iliac artery was ligated preemptively in all patients. Total transfusion required ranged from one to six units (mean: 2 units). Number of lymph nodes removed ranged from 15 to 35 (mean: 20). Total peritoneal exposure time ranged from 0 to 70 min (mean: 50 min). None of the patient needed intensive care postoperatively. Gastrointestinal tract (GIT) recovery time ranged from 1 to 4 days (mean of 1.5 days). Total hospital stay ranged from 7 to 15 days (mean: 9 days). On follow-up, one patient had stent (feeding tube) fracture, and the residual fragment was managed by antegrade approach. One patient had ureteroileal anastomotic stricture which was managed by refashioning of the anastomosis (Bricker to Wallace). One patient had stomal stenosis with features of recurrent urinary tract infections and underwent refashioning of stoma with stabilization of renal function. Conclusion: To circumvent the need of postoperative ventilation, intensive care unit admission, and prolonged hospital stay, we advocate retrograde extraperitoneal RC under combined RA (CRA) as preferred approach of surgical intervention in high-risk and elderly patients with little abdominal organ disturbance and early bowel recovery.

Keywords: Bladder cancer, radical retrograde cystectomy, regional anesthesia

How to cite this article:
Khawaja AR, Dar Y, Suhail M, Sofi K, Muzaffar P, Parra S, Malik S, Bhat A, Wani M. Feasibility and safety of retrograde radical cystectomy under combined spinal and epidural anesthesia in high-risk and elderly patients. A single surgeon experience. Urol Sci 2021;32:111-6

How to cite this URL:
Khawaja AR, Dar Y, Suhail M, Sofi K, Muzaffar P, Parra S, Malik S, Bhat A, Wani M. Feasibility and safety of retrograde radical cystectomy under combined spinal and epidural anesthesia in high-risk and elderly patients. A single surgeon experience. Urol Sci [serial online] 2021 [cited 2022 Nov 30];32:111-6. Available from: https://www.e-urol-sci.com/text.asp?2021/32/3/111/326931

  Introduction Top

Radical cystectomy (RC) with pelvic lymphadenectomy is the standard treatment for muscle invasive bladder cancer (MIBC) and a valid treatment option for selected patients with high-grade non-MIBC (NMIBC). Improvements in surgical techniques and modern perioperative care have substantially decreased the rate of perioperative complications and lowered the operative mortality rate.[1] However, this procedure remains prone to complication and is associated with significant perioperative and long-term morbidity ranging from 19% to 64%.[2] RC is a technically challenging operation, and hence, reduction in morbidity and mortality is difficult to achieve; the situation becomes more challenging in patients with multiple comorbid conditions.

With an extraperitoneal approach with extra peritonealization of the conduit being introduced to reduce morbidity, the commonly used surgical technique is the descending transperitoneal approach. Early complications that occur in 20% to 58% of patients after RC include mostly gastrointestinal motility disorders, which occur in almost one third of patients.[3],[4]

The preferred mode of anesthesia in these patients is a combination of general and epidural anesthesia which usually remains challenging in elderly patients with multiple comorbidities. This category of patients usually requires postoperative (postop) ventilation and intensive care, especially in overburdened high output government tertiary health facilities like the study site. The availability of this postop care is scarce. For these reasons, we aimed to assess the advantages of a retrograde approach under regional anesthesia (RA) in our study.

  Materials and Methods Top

This study was retrospective in design, conducted in the Department of Urology, SKIMS Soura, J and K, India, over a period of 8 years from 2012 to 2020. Signed informed consent was obtained from all the study participants. A total of 37 patients, diagnosed with MIBC, were included in the study. Cardiovascular, renal function, and pulmonary function assessments were used to evaluate the presence of comorbidities and determine the need for preoperative medical interventions to improve, or even stabilize, these comorbidities. Nutritional assessment and other required interventions were also carried out. The preanesthetic risk was quantified using the American Society of Anesthesiologists physical status classification score.

All patients underwent an oncological evaluation to determine and discuss the risks and benefits of neoadjuvant or adjuvant chemotherapy according to the pathological and clinical stage respectively. However, based on patients' desire, age, and comorbidities, none of the patients underwent any form of neoadjuvant or adjuvant chemotherapy. One day before surgery, mechanical 24-h bowel preparation plus perioperative antibiotics with antithrombotic prophylaxis was administered. The operations were performed by a single surgeon. All the patients received combined spinal epidural (CSE) anesthesia under aseptic conditions in lateral position. The CSE was performed at two separate levels. After placement of epidural catheter at T10 and a negative cerebrospinal fluid, blood and test dose, a spinal block was performed at L3-4 level using 3.5 ml of hyperbaric bupivacaine 0.5% and 20 mcg of fentanyl. Only two patients received isobaric ropivacaine 0.5% as spinal drug. Epidural was activated 2 h after the start of surgery. All the patients received standard dose of dexmedetomidine infusion for sedation and comfort.

Ethical elements

The study was approved by the departmental committee that also looks into ethical aspects of biomedical research conducted in the department. This is a retrospective audit of the anonymized records, and the committee did not deem it necessary to refer the study to the main institutional ethics committee (IEC) as there was no ethical issue involved and hence exempt from ethical review.

Operative procedure

  1. Extraperitoneal surgery [Figure 1] was performed by midline infra-umbilical incision regardless of whether a conduit or neobladder was reconstructed
  2. The space of Retzius was entered inferiorly, and a standard bilateral pelvic lymph node dissection (PLND) was performed with ligation of bilateral internal iliac artery sparing posterior branch before the cystectomy, including the nodes along the distal half of the common iliac vessels together with its bifurcation
  3. Following this, retrograde retropubic dissection of the prostate and the bladder was performed. The dissected prostate and bladder were pulled up [Figure 2], with only peritoneum at the level of the bladder dome attached to the surrounding peritoneal flaps. In patients with clinical NMIBC, the peritoneum was preserved as much as possible, and in those with clinical MIBC, the peritoneum was completely removed together with the bladder. This minimized peritoneal defects
  4. The ureter close to the ureterovesical junction was identified, and samples were sent for histological examination
  5. Before urinary tract reconstruction with the neobladder or ileal conduit, the peritoneal cavity was reconstructed after isolation of an ileal loop, reestablishment of bowel continuity cephalad to the ileal loop, and closure of the mesenteric window
  6. Cutaneous ureterostomy, ileal neobladder, or ileal conduit were performed as urinary diversion in our study. Cutaneous ureterostomies were performed in patients who had severe renal failure and could not tolerate bowel diversion. Orthotopic ileal neobladders were carried out in patients with reliable active postoperative participation to ensure proper maintenance of the reservoir. All procedures of urinary diversions were carried out without compromising oncologic principles, after discussion with the patients and written consent was obtained. Of the 37 patients, 32 underwent ileal conduit, 1 underwent ileal neobladder, and 4 underwent cutaneous ureterostomy. In patients who underwent cutaneous ureterostomy, the peritoneal cavity was closed shortly after the procedure and may not need to be opened if the cancer is clinically superficial
  7. Bilateral pelvic or peritoneal cavity drainage tubes were removed when the output remained at <30 ml
  8. Surgical parameters, perioperative minor and major complications, pathology, need for intensive care or cardiac monitoring, and duration of hospital stay were documented. All complications were further classified according to the Clavien-Dindo classification of surgical complications. Surgical parameters included the number of lymph nodes dissected in PLND, operation time, duration of abdominal organ exposure (time interval between the peritoneal incision and the closure of the peritoneal cavity), blood loss, and transfusion rate.
Figure 1: Infraumbilical extraperitoneal cystoprostatectomy specimen with peritoneum intact. White arrow showing peritoneal attachment

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Figure 2: Anterior and posterior leafs of peritoneum with completion of cystoprostatectomy specimen. White thick arrows showing two leafs of peritoneum

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i. Early complications were recorded within 2 months of surgery or during patient hospitalization. All the resected samples were subjected to pathologic analyses. The follow-up period was 4 years. None of the patients which were included in our study received adjuvant chemotherapy, and all of them were followed up every 3 months in the 1st year and subsequently every 6-month postsurgery. Physical examination, blood parameters, cytology, and imaging (abdominal ultrasound, thoracic radiography, and computed tomography of the pelvis) were carried out to detect local recurrences and distant metastases.

  Results Top

Thirty-seven patients were operated on and followed up over a period of 4 years. Thirty (30) of these patients were males while seven were females, with a median age of 74.5 years (70–83 years). The American Society of Anesthesiologists (ASA) score was II in 20 patients, III in 15 patients, and IV in two patients. All the patients in the study had significant comorbidities [Table 1]. Twenty-five (25) patients had hemoglobin level <8 gr/dl and were given preoperative blood transfusions.
Table 1: Patient characteristics

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In total, operative time [Table 2] ranged from 2.5 to 5.5 h (mean: 3.5 h) and no major intraoperative complications occurred. Number of lymph nodes removed ranged from 15 to 35 in number. Intraoperatively, six patients required blood transfusion of between one and six units. After surgery, all patients were moved directly from recovery to the general urology ward with inbuilt extensive monitoring and no need for the intensive care unit (ICU). Regarding early postoperative complications, prolonged paralytic ileus occurred in one patient, which was managed conservatively. In our study, three patients developed surgical site infections, which were also managed conservatively with antiseptic dressing. The length of hospital stay in our patients ranged from 7 to 15 days, with an average of 9 days.
Table 2: Surgical Parameters

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  Discussion Top

RC remains the most effective oncological treatment for MIBC and refractory NIMBC. However, the surgical management of MIBC in elderly patients is challenging. Age and comorbidities often render these patients poor candidates for radical surgery.[4] In our study, we investigated the feasibility and safety of RC through extraperitoneal route under CRA in a selected group of high-risk patients. Advantages of RA are lower morbidity and mortality compared to general anesthesia (GA) including in many urogenital surgeries.[5],[6] Offering superior pain relief and early mobilization, especially when local anesthetic dose is combined with an adjuvant,[7] segmental epidural anesthesia selectively blocks pain fibers from the surgical site.[8] Besides the associated complications, cost of GA is higher than RA.[9] Sedation is known to increase patient's acceptance of RA and to greatly improve patient's well-being during the surgical procedure.[10] Dexmedetomidine as a sedative agent seems to decrease perioperative opioid consumption and improve pain scores.[11] Where epidural anesthesia with local anesthetic agents has a favorable effect on intestinal blood flow during colorectal surgery, epidural anesthesia/analgesia has been demonstrated to improve postoperative outcome and attenuate the physiologic response to surgery.[12] There is an increasing evidence that thoracic epidural blockade has an important role in modifying tissue microperfusion and protecting microcirculatory weak units from ischemic damage.[13] Majority of the patients in this study were males, and the median age of the patients was 74.5 years. This is not surprising because bladder cancer has been shown to be 3–4 times more common in males than females and age is a risk factor for bladder cancer. The incidence of bladder cancer increases with age,[14] occurring mostly in the sixth decade of life. Specifically, two previous studies observed that the incidence of invasive bladder cancer between the ages of 60–69 years is 0.96% and this increases sharply to 3.5% in people who are 70 years or older.[15],[16]

In our study, duration of operative time ranged from 2.5 to 4.5 h with a mean of 3.5 h while peritoneal exposure time ranged from 0 to 70 min with a mean time of 50 min. This compares well, though higher, with an earlier study by Zaytoun et al.[17] where they reported that the duration of retrograde RC in their study was 240–360 min with a mean of 300 min. More consistent with our result is the study by Qin et al.[18] whose duration of procedure was 2.2–5.0 h with a median of 4 h and peritoneal exposure time ranging between 0 and 75 min with a median of 45 min.

In view of underlying comorbidity, most of the patients were subjected to preoperative echo and further testing if warranted. The two patients in our study with ASA physical status IV received spinal anesthesia (isobaric ropivacaine 0.5%) with minimal hemodynamic effects and prolonged analgesic effect. In our study, blood loss during the procedure ranged from 200 to 1500 ml with a mean of 400 ml and a resulting transfusion requirement of 1–6 units. This finding parallels the literature on blood loss during RC, which documented a median blood loss of 600 ml (range: 100–3000 ml).[19] While lymph node yield in our study ranged from 15 to 35, with an average of 20 nodes, thus suggesting better survival outcomes, we found that retrograde RC does not compromise oncological principles of RC since both surgical margin and lymph node yield were adequate. This is in line with the finding of a previous study by Herr et al.[20] that in patients from whom at least ten lymph nodes were removed, 5-year survival rate improved from 44% to 61%.

In our study, three patients developed surgical site infection [Table 2], which was managed conservatively with antiseptic dressing. Patients who underwent retrograde RC had small infra incision and brief opening of the peritoneal cavity that aided prevention of wound-related complications. Moreover, small incision also helped in reducing respiratory complications.[21] One patient had prolonged (4 days) ileus which was managed conservatively by Ryles tube suction and fluid electrolyte balance. We observed early Gastrointestinal (GIT) recovery time and discharge from hospital compared to transperitoneal radical cystectomy.[21] Postoperative GIT recovery (when patient expels flatus) in our study ranged from 1 to 4 days (average of 1.5 days) and length of hospital stay was 7–15 days (average of 9 days). By contrast, Qin et al.'s[18] study reported a postoperative GIT recovery period of 1–12 days (median: 2.5 days) and length of hospital stay was 10–21 days with a median of 13 days.

Concerning anesthetic strategy, we chose CRA because of its obvious advantages. Regional anaeathesia (RA) is safe ,efficacious and reduces the risk of postoperative respiratory and cardiovascular complications,[5],[22] thus obviating the need for postop intensive care. This was evident in our study, as all our patients were moved to the urology ward postsurgery. Tzortis et al.[23] reported a similar finding that all their patients, having undergone RC under CRA, had no need for the ICU. In addition, CRA provides adequate muscle relaxation and facilitates the return of normal bowel function.[6] With epidural blockade limiting protein catabolism after cystoprostatectomy, increasing the simulating effect of parenteral alimentation on protein synthesis, and reducing postoperative morbidity and mortality,[24] of pivotal importance is its role in reducing intraoperative blood loss and in controlling postoperative pain with minimal analgesic use.[25] With epidural catheter enabling administration of additional doses of local anesthetic and postoperative pain management, on the other hand, spinal anesthesia is characterized by quick installation of motor and sensory blockade and significantly less quantity of local anesthetic is used compared to epidural anesthesia.

Likewise, Friedrich-Freksa et al.[26] reported the effectiveness of RA in RC and urinary diversion and the possible association with reduced postoperative risk. Furthermore, De Nunzio et al.[27] reported that extraperitoneal RC with ureterocutaneostomy under spinal anesthesia was associated with limited morbidity and mortality.

The combination of CRA with on-demand postop epidural analgesia and extraperitoneal approach helped to reduce operative time, blood loss, and wound infection. It boosted early bowel recovery and reduced the need for postop ventilator and ICU stay. Finally, in most of our patients, we were able to design urinary diversions in the form of ileal conduit or orthotopic neobladder, which is usually avoided in elderly and high-risk patients. Although late complications such as stomal stenosis, urinary tract infections, and postoperative urinary tract dilatation in conjunction with renal impairment might occur, only one patient had stomal stenosis, which was managed by repairing the stoma under RA. One patient had urinary leak, which was confirmed by drain creatinine >10 times serum creatinine, and the patient was managed conservatively by prolonged drainage. Another patient had bilateral ureteroileal stricture which was managed initially by percutaneous nephrostomy [Figure 3] followed by antegrade stenting. Subsequently, the patient underwent refashioning of the anastomosis [Figure 4]. A patient had stomal stent fracture on the left side while attempting to routinely remove the ureteroileal anastomosis stent. Percutaneous antegrade access was used to retrieve the proximal end of stent.
Figure 3: Right and left ureteroenteric stricture marked with white arrows

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Figure 4: Wallace ureterointestinal anastomosis for ureterointestinal stricture. Two ureters joined (marked with white arrow) for end-to-end anastomosis

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This present study results showed that elderly bladder cancer patients with significant comorbidities can safely undergo RC through extraperitoneal approach with combined spinal and epidural anesthesia and benefit from its advantages. These advantages of RA for cystoprostatectomy include hypotensive anesthesia during the procedure, patient's consciousness, feeling less pain, early ambulation, and early bowel recovery. Moreover, in our study, those with high ASA score and underwent cutaneous ureterocutaneostomy were allowed to drink and eat the next day after the procedure.

A possible limitation of our study is the retrospective design. Another limitation is that our study had a relatively small number of patients.

  Conclusion Top

Our study shows that elderly patients with multiple significant comorbidities can safely undergo RC with the help of RA. Allowing for little abdominal organ disturbance and early bowel recovery, retrograde extraperitoneal approach is a good option for patients with localized MIBC. We thus advocate retrograde extraperitoneal RC under CRA as a preferred approach for surgical intervention in high-risk and elderly patients.

Ethical policy

The study was approved by the departmental committee that also looks into ethical aspects of biomedical research conducted in the department. This is a retrospective audit of the anonymized records, and the committee did not deem it necessary to refer the study to the main IEC as there was no ethical issue involved and hence exempt from ethical review.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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