Is there a measurable association of epidural use at cystectomy and postoperative outcomes? A population-based study

Introduction: Thoracic epidural analgesia (TEA) is commonly used to manage postoperative pain and facilitate early mobilization after major intra-abdominal surgery. Evidence also suggests that regional anesthesia/ analgesia may be associated with improved survival after cancer surgery. Here, we describe factors associated with TEA at the time of radical cystectomy (RC) for bladder cancer and its association with both short-and long-term outcomes in routine clinical practice. Methods: All patients undergoing RC in the province of Ontario between 2004 and 2008 were identified using the Ontario Cancer Registry (OCR). Modified Poisson regression was used to describe factors associated with epidural use, while a Cox proportional hazards model describes associations between survival and TEA use. Results: Over the five-year study period, 1628 patients were identified as receiving RC, 54% (n=887) of whom received TEA. Greater anesthesiologist volume (lowest volume providers relative risk [RR] 0.85, 95% confidence interval [CI] 0.75. 0.96) and male sex (female sex RR 0.89, 95% CI 0.79. 0.99) were independently associated with greater use of TEA. TEA use was not associated with improved short-term outcomes. In multivariable analysis, TEA was not associated with cancer-specific survival (hazard ratio [HR] 1.02, 95% CI 0.87. 1.19; p=0.804) or overall survival (HR 0.91, 95% CI 0.80. 1.03; p=0.136). Conclusions: In routine clinical practice, 54% of RC patients received TEA and its use was associated with anesthesiologist provider volume. After controlling for patient, disease and provider variables, we were unable to demonstrate any effect on either short-or long-term outcomes at the time of RC.