Timing of perioperative transversus abdominis plane block at the time of radical cystectomy does not affect perioperative outcomes

Surgeon-administered regional nerve blocks during radical cystectomy: a feasibility study

OBJECTIVE

To describe the technique for surgeon-administered, ultrasound-guided transversus abdominis plane (SU-TAP) blocks performed during radical cystectomy as a component of multimodal, perioperative pain management.

METHODS

Retrospective, case series of patients receiving SU-TAP blocks just prior to incision for RC. TAP blocks were performed by the surgeon with a standard technique using US guidance to instill an anesthetic solution. The primary outcome was opioid consumption at the intervals of 0-12, 12-24, 24-36, and 36-48 h postoperatively. Opioid consumption was reported as oral morphine milligram equivalents (MME). Secondary outcomes included time to perform SU-TAP blocks, and safety of block procedure.

RESULTS

34 patients were included. During the median length of stay of 4 days (interquartile range [IQR] 3-7), only 30/34 (88%) of patients required opioids within the first 12 h post-op, decreasing to 38% by 48 h post-op. The median consumption decreased in the first 48 h from 21 MMEs (IQR 9-38) to 10 MMEs (IQR 8-15) at the 0-12 and 36-48 h intervals, respectively. The median time to perform block procedure was 6 min (IQR 4-8 min) and there were no safety events related to the SU-TAP blocks. Limitations include no comparative arm for opioid consumption.

CONCLUSION

Our data suggest that urologists may feasibly perform US-guided TAP blocks as a practical, efficient, and safe method of regional anesthesia. SU-TAP blocks should be considered in ERAS protocols for RC. Future comparative studies on opioid consumption compared to local infiltration and alternative block techniques are warranted.

Posterior quadratus lumborum block versus epidural analgesia for postoperative pain management after open radical cystectomy: A randomized clinical trial

BACKGROUND

In open abdominal surgery, continuous epidural analgesia is commonly used method for postoperative analgesia. However, ultrasound (US)-guided fascial plane blocks may be a reasonable alternative.

METHODS

In this randomized controlled trial, we compared posterior quadratus lumborum block (QLB) with epidural analgesia for postoperative pain after open radical cystectomy (ORC). Adult patients aged 18-85 with bladder cancer (BC) scheduled for open RC were randomized in two groups. Exclusion criteria were complicated diabetes mellitus type I, lack of cooperation, and persistent pain for reasons other than BC. In one group, a bilateral US-guided single injection posterior QLB was performed with 3.75 mg/ml ropivacaine 20 ml/side. In the other group, continuous epidural analgesia with ropivacaine was used. Basic analgesia was oral paracetamol 1000 mg three times daily, and long-acting opioid twice daily in both groups. All patients had patient-controlled rescue analgesia with oxycodone. Postoperative cumulative rescue opioid consumption was recorded for the day of surgery, and the following 2 postoperative days (POD 0-2). Secondary outcomes were postoperative pain and nausea and vomiting.

RESULTS

In total, 20 patients (QLB), and 19 patients (epidural analgesia) groups, were included in the analyses. Cumulative rescue opioid consumption on POD 0, being of duration 9-12 h, was 14 mg (7.6-33.3) in the QLB group versus 6.1 mg (2.0-16.1) in the epidural analgesia group, p = 0.089, and as doses, 8 doses (3.6-15.7) versus 4 doses (1.3-8.5), p = .057. On POD 1 consumption was 25.3 mg (11.0-52.9) versus 18.0 mg (14.4-43.7), p = .749, and as doses 12 (5.5-23.0) versus 10 (8-20), p > .9, respectively. On POD 2 consumption was 19.1 mg (7.9-31.0) versus 18.0 mg (5.4-27.6) p = .749, and as doses 8.5 (5.2-14.7) versus 11 (3.0-18.0) p > .9, respectively.

CONCLUSION

Opioid consumption did not differ significantly between posterior QLB and an epidural infusion with ropivacaine for the first 2 postoperative days following RC.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03328988.

Updates on enhanced recovery after surgery for radical cystectomy

Enhanced Recovery after Surgery (ERAS) is a multimodal pathway that provides evidence-based guidance for improving perioperative care and outcomes in patients undergoing surgery. In 2013, the ERAS society released its original guidelines for radical cystectomy (RC) for bladder cancer (BC), adopting much of its supporting data from colorectal literature. In the last decade, growing interest in ERAS has increased RC-specific ERAS research, including prospective randomized controlled trials (RCTs). Collective data suggest ERAS contributes to improved complication rates, decreased hospital length-of-stay, and/or time to bowel recovery. Various institutions have adopted modified versions of the ERAS pathway, yet there remains a lack of consensus on the efficacy of specific ERAS items and standardization of the protocol. In this review, we summarize updated evidence and practice patterns of ERAS pathways for RC since the introduction of the original 2013 guidelines. Novel target interventions, including use of immunonutrition, prehabilitation, alvimopan, and methods of local analgesia are reviewed. Finally, we discuss barriers to implementing and future steps in advancing the ERAS movement.

Surgeon-Administered Transversus Abdominis Plane (TAP) Block is Associated with Decreased Opioid Usage and Length of Stay following Radical Cystectomy

OBJECTIVE

To study the effect of surgeon-administered Transversus Abdominis Plane block (sTAP) on opioid usage and length of stay (LOS).

METHODS

Starting in April 2018, two surgeons at our institution gradually introduced sTAP for radical cystectomy (RC) patients. We performed a retrospective observational cohort analysis of RC patients catalogued in a prospectively maintained database using the ERAS Interactive Auditing System. Two surgeons adopted the sTAP block technique in April 2018. We included patients undergoing RC for bladder malignancy under ERAS protocol between 1/2017-8/2020. Primary outcomes included LOS, and POD0-3 total opioids consumption measured by morphine milligram equivalents (MME). Multivariable linear or logistic models evaluated the association of TAP with outcomes while controlling for potential confounders.

RESULTS

Among 178 patients included in analysis, 84 patients underwent sTAP block and 94 did not. Multivariable analysis demonstrated significantly lower POD0-3 total opioid usage (106.4 vs 192.2 MME, p=.004), and mean LOS (5.6 vs 7.7 days, p<.001) among the sTAP group.

CONCLUSION

sTAP appears to be an effective adjunct to RC care associated with improved LOS, and POD0-3 opioid consumption. Further studies are needed to optimize TAP block technique and anesthetic composition.