Local Anesthetics During Prosatectomy May Improve Outcomes

Adding a spinal or epidural painkiller to general anesthesia during prostatectomy may benefit long-term patient outcomes, according to a large retrospective study. Researchers at the Mayo Clinic in Rochester, Minnesota and colleagues analyzed medical records and patient outcomes over a median of 9 years.

After adjusting for comorbidities and factors such as positive surgical margins, and adjuvant hormonal and radiation therapies within 90 postoperative days, the analysis found that general anesthesia alone, but not the combination of general anesthesia plus a localized painkiller, was associated with an increased risk of systemic prostate cancer progression (hazard ratio [HR] = 2.81, P = .008) and a higher overall mortality (HR = 1.32, P = .047). Prostate cancer deaths were also higher, but this outcome was not statistically significant (HR = 2.2, P = .091).

The results are published in the British Journal of Anaesthesia.

Randomized, prospective studies are needed to validate these results.

Because the use of opioids as painkillers during and after surgery may suppress the immune system’s defense against cancer, Juraj Sprung, MD, PhD, anesthesiologist at the Mayo Clinic and colleagues hypothesized that patients who are given a supplemental neuraxial anesthesia such as an epidural or spinal anesthesia during surgery may have better outcomes compared with those given opioids for their pain. Neuraxial anesthesia has been shown to lower perioperative stress and the need for systemic opioid painkillers, preserving the function of immune cells and lowering recurrence rates and progression in animal models.

Whether neuraxial anesthesia could lower recurrence in humans is not clear and has only been studied in small, retrospective studies.

The researchers analyzed outcomes of 1,642 patients who were given general and neuraxial anesthesia at the Mayo Clinic to 1,642 matched patients who had general anesthesia only. Patients were matched for age, year of surgery, pathologic stage, Gleason scores, and presence of disease in the lymph nodes. All patients had surgery between 1991 and 2005.

The median age of patients was 61 years. The majority of patients had stage IIB disease and a Gleason score of 6 or less.

In the neuraxial analgesia group, 83% of the patients were given a spinal block with morphine; hydromorphone was used less frequently, in a total of 353 patients.

It is not clear what part of the management of anesthesia or which mechanism may have contributed to the apparent benefit of including neuraxial analgesia in the prostatectomy surgery.

“Although our results suggest the possibility of the beneficial effects of regional anesthetic techniques in some oncological outcomes after prostatectomy, we caution that the result from an observational study, such as ours, can only be viewed as hypothesis-generating and need to be confirmed (or refuted) in future prospective, randomized trials,” said the authors in their conclusion.

"Provided future studies confirm what we have found in this study, maybe down the line this would be a standard of care for pain management in patients undergoing cancer surgery,” said Dr. Sprung in a statement.