Comparison of 4 local anesthetic techniques for open radical cystectomy: A prospective, randomized controlled trial

Open radical cystectomy with urinary diversion is associated with high morbidity, partly due to perioperative opioid use and delayed return of bowel function. We designed a prospective, randomized controlled trial to compare 4 common perioperative analgesic techniques.

A total of 160 patients between 2019 and 2021 were prospectively enrolled and randomized into 4 groups - thoracic epidural anesthesia (TEA), rectus sheath block (RSB), surgeon infiltration (SI) with either liposomal bupivacaine (LB) or standard bupivacaine (SB). The primary outcome was Visual Analog Scale (VAS) scores at different time points. Secondary outcomes including opioid use, incidence of treatment related side effects, and length of stay (LOS) were measured.

There was no statistical difference regarding VAS scores among 4 groups at 24-, 48, or 96-hour marks. At 72-hour, both TEA and SI with SB had lower VAS scores compared to SI with LB at rest. Compared to SI with SB, TEA had lower cumulative opioid use in first 72 hours postoperatively. The opioid use at individual timepoint, treated related side effects and LOS were similar across groups. TEA was not associated with increased incidence of hypotension, AKI, or delayed ambulation. The ileus rates were higher in SI groups than in TEA and RSB groups (not statistically significant). Limitations include variability in analgesic techniques and timing to transition to PO opioids.

Four analgesic methods perform similarly regarding pain control, opioid use, treatment related side effects and LOS in radical cystectomy.