Introduction: Radical retropubic prostatectomy (RRP) is associated with an increased risk of intraoperative blood loss and the necessity of transfusions. This prospective randomised clinical study evaluates the influence of thoracic epidural analgesia (TEA) on blood loss in RRP. Materials and Methods: 235 patients were randomised: TEA in group 1 (n = 116; general anaesthesia + TEA) comprised continuous administration of 0.25% bupivacaine, while group 2 (n = 119; general anaesthesia alone) received intravenous analgesia with fentanyl (intubation: 2 µg/kg; maintenance: 0.1- 0.3 mg). A restrictive infusion regimen (<1,000 ml until specimen removal) was administered in both groups. Blood loss, infusion rates and anaesthesiological parameters were recorded and analysed using regression models and analyses of variance. Results: Haemoglobin difference between the pre- and the first postoperative day (group 1: 3.35 ± 1.16 g/dl; group 2: 3.56 ± 1.42 g/dl; p = 0.19), overall blood loss (group 1: 665 ± 431.5 ml; group 2: 705 ± 881 ml; p = 0.73) and transfusion rates (0.4% intraoperatively; 2.55% postoperatively; p = 1.0) did not show group differences. In regression analysis blood loss was influenced by preoperative haemoglobin levels (p < 0.0001), patients' weight (p = 0.018) and duration of the operation (p = 0.017). Conclusions: This study did not demonstrate a direct impact of TEA on intraoperative blood loss and transfusion rates in RRP. Further randomised clinical trials are needed to evaluate an impact of the different anaesthetic procedures presented alone or in combination on blood loss.

Keywords:
Thoracic epidural analgesia, Radical retropubic prostatectomy, Blood loss, Prospective randomised clinical trial
1.
Budaus L, Isbarn H, Schlomm T, Heinzer H, Haese A, Steuber T, Salomon G, Huland H, Graefen M: Current technique of open intrafascial nerve-sparing retropubic prostatectomy. Eur Urol 2009;56:317-324.
2.
Chang SS, Duong DT, Wells N, Cole EE, Smith JA Jr, Cookson MS: Predicting blood loss and transfusion requirements during radical prostatectomy: the significant negative impact of increasing body mass index. J Urol 2004;171:1861-1865.
3.
Friederich PW, Henny CP, Messelink EJ, Geerdink MG, Keller T, Kurth KH, Buller HR, Levi M: Effect of recombinant activated factor VII on perioperative blood loss in patients undergoing retropubic prostatectomy: a double-blind placebo-controlled randomised trial. Lancet 2003;361:201-205.
4.
McCullough TC, Roth JV, Ginsberg PC, Harkaway RC: Estimated blood loss underestimates calculated blood loss during radical retropubic prostatectomy. Urol Int 2004;72:13-16.
5.
Shir Y, Raja SN, Frank SM, Brendler CB: Intraoperative blood loss during radical retropubic prostatectomy: epidural versus general anesthesia. Urology 1995;45:993-999.
6.
Tagawa ST, Dorff TB, Rochanda L, Ye W, Boyle S, Raghavan D, Lieskovsky G, Skinner DG, Quinn DI, Liebman HA: Subclinical haemostatic activation and current surgeon volume predict bleeding with open radical retropubic prostatectomy. BJU Int 2008;102:1086-1091.
7.
Sayah DM, Looney MR, Toy P: Transfusion reactions: newer concepts on the pathophysiology, incidence, treatment, and prevention of transfusion-related acute lung injury. Crit Care Clin 2012;28:363-372, v.
8.
Schostak M, Matischak K, Muller M, Schafer M, Schrader M, Christoph F, Miller K: New perioperative management reduces bleeding in radical retropubic prostatectomy. BJU Int 2005;96:316-319.
9.
Freise H, Van Aken HK: Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth 2011;107:859-868.
10.
Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-383.
11.
Wolters U, Wolf T, Stutzer H, Schroder T: ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth 1996;77:217-222.
12.
Fant F, Axelsson K, Sandblom D, Magnuson A, Andersson SO, Gupta A: Thoracic epidural analgesia or patient-controlled local analgesia for radical retropubic prostatectomy: a randomized, double-blind study. Br J Anaesth 2011;107:782-789.
13.
McLeod GA, Dell K, Smith C, Wildsmith JA: Measuring the quality of continuous epidural block for abdominal surgery. Br J Anaesth 2006;96:633-639.
14.
Ahlers O, Nachtigall I, Lenze J, Goldmann A, Schulte E, Hohne C, Fritz G, Keh D: Intraoperative thoracic epidural anaesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. Br J Anaesth 2008;101:781-787.
15.
Graefen M, Huland H: Technique of nerve-sparing radical retropubic prostatectomy (in German). Urologe A 2004;43:156-159.
16.
Heidenreich A, Varga Z, Von Knobloch R: Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis. J Urol 2002;167:1681-1686.
17.
Bundesärztekammer: Guidelines on Therapy with Blood Components and Plasma Derivatives, ed 3 (in German). Cologne, Deutscher Ärzte-Verlag GmbH, 2003.
18.
Egevad L, Granfors T, Karlberg L, Bergh A, Stattin P: Prognostic value of the Gleason score in prostate cancer. BJU Int 2002;89:538-542.
19.
Schostak M, Baumunk D, Jagota A, Klopf C, Winter A, Schafers S, Kossler R, Brennecke V, Fischer T, Hagel S, Hochel S, Jakel D, Lehsnau M, Krege S, Ruffert B, Pretzer J, Becht E, Zegenhagen T, Miller K, Weikert S: Time trends in prostate cancer surgery: data from an Internet-based multicentre database. BJU Int 2012;109:355-359.
20.
Barré C, Pocholle P, Chauveau P: Minimal blood loss in patients undergoing radical retropubic prostatectomy. World J Surg 2002; 26:1094-1098.
21.
Dunet F, Pfister C, Deghmani M, Meunier Y, Demeilliers-Pfister G, Grise P: Clinical results of combined epidural and general anesthesia procedure in radical prostatectomy management. Can J Urol 2004;11:2200-2204.
22.
O'Connor PJ, Hanson J, Finucane BT: Induced hypotension with epidural/general anesthesia reduces transfusion in radical prostate surgery. Can J Anaesth 2006;53:873-880.
23.
Tikuisis R, Miliauskas P, Samalavicius NE, Zurauskas A, Sruogis A: Epidural and general anesthesia versus general anesthesia in radical prostatectomy. Medicina (Kaunas) 2009;45:772-777.
24.
Eroglu A, Uzunlar H, Erciyes N: Comparison of hypotensive epidural anesthesia and hypotensive total intravenous anesthesia on intraoperative blood loss during total hip replacement. J Clin Anesth 2005;17:420-425.
25.
Wuethrich PY, Studer UE, Thalmann GN, Burkhard FC: Intraoperative continuous norepinephrine infusion combined with restrictive deferred hydration significantly reduces the need for blood transfusion in patients undergoing open radical cystectomy: results of a prospective randomised trial. Eur Urol 2013, Epub ahead of print.
26.
Larsen R, Kleinschmidt S: Controlled hypotension (in German). Anaesthesist 1995;44:291-308.
27.
Gattas DJ, Dan A, Myburgh J, Billot L, Lo S, Finfer S: Fluid resuscitation with 6% hydroxyethyl starch (130/0.4) in acutely ill patients: an updated systematic review and meta-analysis. Anesth Analg 2012;114:159-169.
28.
Davies BJ, Chung SY, Nelson JB: Delayed intraoperative hydration limits blood loss during radical retropubic prostatectomy. Urology 2004;64:712-716.
29.
Augustin H, Hammerer P, Graefen M, Palisaar J, Noldus J, Fernandez S, Huland H: Intraoperative and perioperative morbidity of contemporary radical retropubic prostatectomy in a consecutive series of 1,243 patients: results of a single center between 1999 and 2002. Eur Urol 2003;43:113-118.
30.
Lepor H, Kaci L: Contemporary evaluation of operative parameters and complications related to open radical retropubic prostatectomy. Urology 2003;62:702-706.
31.
Shir Y, Raja SN, Frank SM: The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical prostatectomy. Anesthesiology 1994;80:49-56.
32.
Gupta A, Fant F, Axelsson K, Sandblom D, Rykowski J, Johansson JE, Andersson SO: Postoperative analgesia after radical retropubic prostatectomy: a double-blind comparison between low thoracic epidural and patient-controlled intravenous analgesia. Anesthesiology 2006;105:784-793.
33.
Frank E, Sood OP, Torjman M, Mulholland SG, Gomella LG: Postoperative epidural analgesia following radical retropubic prostatectomy: outcome assessment. J Surg Oncol 1998;67:117-120.
34.
Heller AR, Litz RJ, Djonlagic I, Manseck A, Koch T, Wirth MP, Albrecht DM: Combined anesthesia with epidural catheter. A retrospective analysis of the perioperative course in patients undergoing radical prostatectomy (in German). Anaesthesist 2000;49:949-959.
35.
Hong JY, Lee SJ, Rha KH, Roh GU, Kwon SY, Kil HK: Effects of thoracic epidural analgesia combined with general anesthesia on intraoperative ventilation/oxygenation and postoperative pulmonary complications in robot-assisted laparoscopic radical prostatectomy. J Endourol 2009;23:1843-1849.
36.
Kirsh EJ, Worwag EM, Sinner M, Chodak GW: Using outcome data and patient satisfaction surveys to develop policies regarding minimum length of hospitalization after radical prostatectomy. Urology 2000;56:101-106; discussion 106-107.
37.
Bonnet F, Marret E: Influence of anaesthetic and analgesic techniques on outcome after surgery. Br J Anaesth 2005;95:52-58.
38.
Kettner SC, Willschke H, Marhofer P: Does regional anaesthesia really improve outcome? Br J Anaesth 2011;107(suppl 1):i90-i95.
39.
Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy DJ: Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: a retrospective analysis. Anesthesiology 2008;109:180-187.
40.
Oefelein MG, Colangelo LA, Rademaker AW, McVary KT: Intraoperative blood loss and prognosis in prostate cancer patients undergoing radical retropubic prostatectomy. J Urol 1995;154:442-447.
41.
Lloyd JC, Banez LL, Aronson WJ, Terris MK, Presti JC Jr, Amling CL, Kane CJ, Freedland SJ: Estimated blood loss as a predictor of PSA recurrence after radical prostatectomy: results from the SEARCH database. BJU Int 2010;105:347-351.
42.
Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U, Hebert AE, Wiklund P: Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. Eur Urol 2012;62:1-15.
43.
Novara G, Ficarra V, Rosen RC, Artibani W, Costello A, Eastham JA, Graefen M, Guazzoni G, Shariat SF, Stolzenburg JU, Van Poppel H, Zattoni F, Montorsi F, Mottrie A, Wilson TG: Systematic review and meta-analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol 2012;62:431-452.
© 2014 S. Karger AG, Basel
2014
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.