Anesthetic Technique for Radical Prostatectomy Surgery Affects Cancer Recurrence

TLDR

Regional anesthesia and analgesia can reduce perioperative factors that promote residual disease after tumor removal. The study evaluated prostate cancer recurrence comparing general anesthesia with epidural analgesia to general anesthesia with postoperative opioids, and proposes prospective randomized trials to confirm the association. The authors performed a retrospective review of 1994–2003 radical prostatectomy records, comparing patients receiving general anesthesia with epidural analgesia to those with general anesthesia plus opioids, using postoperative PSA rise as the recurrence endpoint. After multivariable adjustment, patients receiving epidural plus general anesthesia had a 57% lower risk of biochemical recurrence (HR 0.43, 95% CI 0.22–0.83), with Gleason score and tumor size also independently predicting recurrence, and propensity‑matched analysis confirmed the reduced risk.

Abstract

Background Regional anesthesia and analgesia attenuate or prevent perioperative factors that favor minimal residual disease after removal of the primary carcinoma. Therefore, the authors evaluated prostate cancer recurrence in patients who received either general anesthesia with epidural anesthesia/analgesia or general anesthesia with postoperative opioid analgesia. Methods In a retrospective review of medical records, patients with invasive prostatic carcinoma who underwent open radical prostatectomy between January 1994 and December 2003 and had either general anesthesia-epidural analgesia or general anesthesia-opioid analgesia were evaluated through October 2006. The endpoint was an increase in postoperative prostate-specific antigen. Results After adjusting for tumor size, Gleason score, preoperative prostate-specific antigen, margin, and date of surgery, the epidural plus general anesthesia group had an estimated 57% (95% confidence interval, 17-78%) lower risk of recurrence compared with the general anesthesia plus opioids group, with a corresponding hazard ratio of 0.43 (95% confidence interval, 0.22-0.83; P = 0.012) in a multivariable Cox regression model. Gleason score and tumor size (percent of prostate involved) were also independent predictors of recurrence (hazards ratios of 1.19 [1.08, 1.52], P = 0.004, and 1.17 [1.03, 1.34] for 10% size difference, P = 0.01, respectively). A similar association between epidural use and recurrence was obtained by comparing patients matched on the propensity to receive epidural versus general anesthesia. Conclusions Open prostatectomy surgery with general anesthesia, substituting epidural analgesia for postoperative opioids, was associated with substantially less risk of biochemical cancer recurrence. Prospective randomized trials to evaluate this association seem warranted.