title: Perioperative management and oncological outcomes following radical cystectomy for bladder cancer: a matched retrospective cohort study.
abstract: OBJECTIVE
  The immune system plays an important role in tumour progression. Systemic opioids are immunosuppressive; thus, theoretically they may promote tumour spread. Our primary aim was to test the hypothesis that general anesthesia (GA) with spinal analgesia (SA) in patients with bladder cancer undergoing radical cystectomy (RC) will both reduce systemic opioid use and improve oncological outcomes. Since blood transfusions also induce immunosuppression, a secondary aim was to evaluate the effect of perioperative transfusions on oncological outcomes.
  
  
  METHODS
  One hundred ninety-five patients who underwent RC with GA+SA from 1998-2007 were matched 1:1 to controls who underwent surgery with GA only using propensity scoring and tumour characteristics known to be highly associated with oncological outcomes. Medical records were reviewed for use of opioids and transfusions. Outcomes were tumour recurrence, cancer-specific mortality, and all-cause mortality. Survival was estimated using the Kaplan-Meier method, and associations of anesthetic technique and transfusions with outcomes were analyzed using stratified multivariable proportional hazard regression.
  
  
  RESULTS
  Systemic opioid use was reduced with GA+SA relative to GA (P < 0.001). There was no difference between groups with respect to all-cause mortality (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.77 to 1.53; P = 0.636), bladder cancer mortality (HR, 1.03; 95% CI, 0.66 to 1.61; P = 0.893), or cancer recurrence (HR, 1.32; 95% CI, 0.86 to 2.02; P = 0.205). Nevertheless, patients who were perioperatively transfused had an increased all-cause mortality (HR, 2.21; 95% CI, 1.11 to 4.40; P = 0.025), and cancer-specific mortality (HR, 2.61; 95% CI, 1.05 to 6.48; P = 0.039).
  
  
  CONCLUSIONS
  In patients undergoing RC, the opioid-sparing effect with SA was not associated with improved oncological outcomes, while blood transfusion was associated with increased mortality.
authors: Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA. weingarten.toby@mayo.edu.
authors: Toby N
authors: TN
authors: Weingarten
authors: Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
authors: Ashley M
authors: AM
authors: Taccolini
authors: Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
authors: Samuel T
authors: ST
authors: Ahle
authors: Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
authors: Kelsey R
authors: KR
authors: Dietz
authors: Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
authors: Shaun S
authors: SS
authors: Dowd
authors: Department of Urology, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors: Igor
authors: I
authors: Frank
authors: Department of Urology, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors: Stephen A
authors: SA
authors: Boorjian
authors: Health Science Research and Biomedical Statistics and Informatics, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors: Prabin
authors: P
authors: Thapa
authors: Health Science Research and Biomedical Statistics and Informatics, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors: Andrew C
authors: AC
authors: Hanson
authors: Health Science Research and Biomedical Statistics and Informatics, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors: Darrell R
authors: DR
authors: Schroeder
authors: Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA. sprung.juraj@mayo.edu.
authors: Juraj
authors: J
authors: Sprung
mesh_terms: D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000768:Anesthesia, General / Q000379:methods; D000775:Anesthesia, Spinal / Q000379:methods; D001803:Blood Transfusion / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D015653:Cystectomy / Q000379:methods*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D019990:Perioperative Care / Q000379:methods; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate; D001749:Urinary Bladder Neoplasms / Q000473:pathology / Q000601:surgery*
chemical_list: D000701:Analgesics, Opioid