Radical cystectomy in frail octogenarians in thoracic continuous spinal anesthesia and analgesia: a pilot study

Background: Radical cystectomy (RC) is the gold standard therapy in nonmetastatic muscle-invasive bladder cancer and is usually performed under general anesthesia (GA). GA is high risk in most older patients due to comorbidities. Continuous spinal anesthesia (CSA) may be an alternative solution to reduce postoperative morbidity in elderly. The aim of this study was to assess the feasibility, morbidity, and mortality of RC performed under CSA in octogenarian patients. Methods: We retrospectively reviewed data of five frail patients aged ⩾80 who underwent RC in CSA. CSA was achieved starting with 2.5 mg hyperbaric bupivacaine plus 25 µg fentanyl. Postoperative analgesia was achieved through the intrathecal catheter, using continuous delivery of levo-bupivacaine 60 mg plus fentanyl 75 µg in 72 hours. Results: Surgery was completed in all cases in CSA. No patients required postoperative intensive care unit admission. Complications were Clavien I for four in three patients, Clavien II for seven in five patients, and Clavien IIIb for one patient. Postoperative consumption of painkillers was negligible. Oral feeding resumed within 3 days in all cases. The mean postoperative stay was 9.6 days. All patients were alive at 3 months of follow up. Conclusions: Management of muscle-invasive bladder cancer (MIBC) in older patients is becoming an important issue due to the continuous aging of the population. Age should not preclude RC, but careful management is mandatory because perioperative morbidity and mortality are increased in the elderly. Our preliminary results show that CSA and analgesia is a feasible option as an additional way to reduce morbidity and mortality in frail octogenarians who require RC.