Introduction:
Regional analgesia is an important component of many enhanced recovery after surgery (ERAS) pathways. While numerous institutions have included regional anesthesia as part of their cystectomy with urinary diversion ERAS pathway, there is little research comparing different regional anesthesia modalities. Transversus abdominus plane block (TAP) is a well-established procedure wherein thoracolumbar nerves between the internal oblique and transversus abdominus muscles are blocked to provide somatic abdominal wall analgesia. Erector spinae plane block (ESP) is a recently described technique wherein local anesthetic is injected just below the erector spinae at the tip of the transverse process, with the medication spreading craniocaudally in the paravertebral and intercostal spaces to provide visceral and somatic analgesia to the abdomen. We compared these modalities in patients undergoing cystectomy with urinary diversion, with primary endpoints of pain scores and total narcotic utilization measured in morphine milligram equivalents (MME).
Methods:
We retrospectively reviewed 77 consecutive patients from March-December 2020 who underwent cystectomy with urinary diversion. Patients who did not undergo ESP or TAP or who utilized chronic narcotics were excluded. Choice of block and whether liposomal bupivacaine or standard bupivacaine with dexamethasone was utilized was based on surgeon and anesthesiologist preference. Pain intensity scores on a scale from one to ten were measured immediately post-operatively and in 24-hour intervals until 72 hours post-operatively. Cumulative MME utilization at 72 hours, return to bowel function (ROBF), and length of stay (LOS) were measured. A Wilcoxon rank sum test was utilized to compare the different modalities at each time point.
Results:
51 patients met inclusion criteria. 17 patients underwent ESP and 34 TAP. ESP patients reported significantly lower pain scores immediately post-operatively (median pain score 4.00 vs. 5.00, p=0.046), at 48 hours (median pain score 3.80 vs. 5.00, p=0.019), and at 72 hours (median pain score 2.50 vs. 4.16, p=0.019). ESP patients utilized less MME after 72 hours than TAP patients (median MME: 62.50 vs. 146.25, p=.008). No significant difference was identified in ROBF or LOS. There was no significant difference in narcotic utilization in patients that received a block with liposomal bupivacaine and those that received a block with standard bupivacaine and dexamethasone.
Conclusion:
Compared to TAP, ESP reduced total narcotic utilization after cystectomy measured in MMEs by an impressive 234%, while also reducing subjective patient pain scores. Increased adoption of ESP could have major impacts on both clinical outcomes and patient satisfaction in patients undergoing cystectomy. Prospective study is needed to better characterize the differences between these two modalities.
Funding: N/A
Image(s) (click to enlarge):
Regional Analgesia After Cystectomy with Urinary Diversion: Erector Spinae Plane Block vs. Transversus Abdominus Plane Block
Category
Bladder Cancer > Muscle Invasive Bladder Cancer
Description
Poster #45
Wednesday, Dec 1
4:00 p.m. - 5:00 p.m.
Bladder 2
Presented By: Daniel A. Igel
Authors:
Daniel A. Igel
Austin Martin
Peter Sullivan
Jeffrey Thompson
John-Paul Pozek
Eugene Lee