Funcke Sandra, Schick-Bengardt Xenia, Pinnschmidt Hans O, Beyer Burkhard, Fischer Marlene, Kahl Ursula, Nitzschke Rainer
Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Perioper Med (Lond). 2022 Oct 3;11(1):49. doi: 10.1186/s13741-022-00281-0.
Spinal anaesthesia preceding general anaesthesia has been conducted for open radical retropubic prostatectomy (RRP) to decrease immediate postoperative pain for many years. Nevertheless, the effectiveness of spinal anaesthesia to reduce postoperative opioid requirements remains unknown. The aim of the present study was to determine the effect of spinal anaesthesia preceding general anaesthesia on opioid requirements, postoperative pain and biochemical cancer-free survival.
This before-and-after effectiveness study investigated effects of two different anaesthesia techniques in 636 patients with RRP. Three hundred eighteen consecutive patients in the SPA group (spinal anaesthesia preceding general anaesthesia) were compared with 318 patients in the GA group (general anaesthesia alone). The primary endpoint of the study was opioid consumption in the post-anaesthesia care unit. Secondary endpoints were intraoperative opioid consumption, postoperative pain, postoperative recovery time, the length of hospital-stay, persistence of pain 1 year after surgery and cancer-free survival. Differences between the groups were analysed by a two-sided t-test, χ-test, Fisher's exact test and Mann-Whitney U test and the influence of possible confounders on opioid consumption with a general linear model. Cancer-free survival was determined by Kaplan-Meier curves and group differences by log-rank tests and multivariable Cox regression analyses.
The total amount of morphine equivalent administered postoperatively was 7.5 [6.9; 8.1] mg in the SPA group and 6.0 [5.5; 6.5] mg in the GA group (mean [95% CI], p < 0.001). The amount of intraoperative sufentanil was 56.9 [55.1; 58.7] μg in the SPA group and 84.5 [82.5; 86.5] μg in the GA group (mean [95% CI], p < 0.001). There was no difference found in the postoperative pain level, length of hospital-stay and pain level 1 year after surgery. Biochemical cancer-free survival was highly related to TNM stage (p < 0.001, pT3 vs. pT2 hazard ratio 5.4 [95%CI 3.3; 9.2]) but not to the type of anaesthesia (p = 0.29).
Spinal anaesthesia preceding general anaesthesia for RRP is associated with increased postoperative opioid consumption compared to general anaesthesia alone. Postoperative pain level and the oncological outcome are not affected by the adjunctive use of spinal anaesthesia. Thus, the addition of spinal anaesthesia to general anaesthesia has no advantage in RRP.
ClinicalTrial.gov, NCT03565705.
多年来，在全身麻醉前行脊髓麻醉已用于开放性耻骨后根治性前列腺切除术（RRP），以减轻术后即刻疼痛。然而，脊髓麻醉降低术后阿片类药物需求量的有效性仍不清楚。本研究的目的是确定全身麻醉前行脊髓麻醉对阿片类药物需求量、术后疼痛及无癌生化生存期的影响。
这项前后对照有效性研究调查了636例RRP患者采用两种不同麻醉技术的效果。将连续318例SPA组（全身麻醉前行脊髓麻醉）患者与318例GA组（单纯全身麻醉）患者进行比较。本研究的主要终点是麻醉后护理单元的阿片类药物消耗量。次要终点包括术中阿片类药物消耗量、术后疼痛、术后恢复时间、住院时间、术后1年疼痛持续情况及无癌生存期。采用双侧t检验、χ检验、Fisher精确检验和Mann-Whitney U检验分析组间差异，并通过一般线性模型分析可能的混杂因素对阿片类药物消耗的影响。采用Kaplan-Meier曲线确定无癌生存期，通过对数秩检验和多变量Cox回归分析确定组间差异。
SPA组术后吗啡等效剂量总量为7.5[6.9；8.1]mg，GA组为6.0[5.5；6.5]mg（均值[95%CI]，p<0.001）。SPA组术中舒芬太尼用量为56.9[55.1；58.7]μg，GA组为84.5[82.5；86.5]μg（均值[95%CI]，p<0.001）。术后疼痛水平、住院时间及术后1年疼痛水平在两组间未发现差异。无癌生化生存期与TNM分期高度相关（p<0.001，pT3与pT2的风险比为5.4[95%CI 3.3；9.2]），但与麻醉类型无关（p=0.29）。
与单纯全身麻醉相比，RRP全身麻醉前行脊髓麻醉与术后阿片类药物消耗量增加有关。脊髓麻醉的辅助使用不影响术后疼痛水平及肿瘤学结局。因此，全身麻醉中加用脊髓麻醉在RRP中并无优势。
ClinicalTrial.gov，NCT03565705。
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