Open radical cystectomy and ileal loop diversion under combined spinal-epidural anaesthesia for the elderly and frail.

BACKGROUND: The association between prolonged general anaesthesia duration in radical cystectomy (RC) and increased complication rates is well established. This study compared clinical outcomes of open RC performed under combined spinal-epidural anaesthesia (CSEA) versus general anaesthesia in elderly and frail patients. METHODS: A retrospective evaluation was conducted on data from patients who underwent open RC at our institution between February 2023 and October 2024. Patients with missing data or previous open abdominal surgery, who underwent additional surgical intervention during RC, or who underwent different urinary diversions from ileal loop diversion were excluded. The study comprised two cohorts, designated as CSEA and general anaesthesia groups. Various demographics, including age, body mass index (BMI), comorbidities, pre-and postoperative blood values, operative times, estimated blood loss, and recovery parameters, were retrospectively analyzed. RESULTS: The CSEA group had a higher mean age than the general anaesthesia group (72.40 ± 9.79 vs. 64.40 ± 10.70 years, p = 0.098), though this difference was not statistically significant. BMI values were similar for both groups (25.50 ± 2.80 and 25.34 ± 4.20 kg/m², p = 0.922). The prevalence of comorbidities was significantly higher in the CSEA group (100% vs. 40%, p = 0.011). The mean preoperative albumin level was lower in the CSEA group (3.23 ± 0.68 vs. 3.97 ± 0.51 mg/dL, p = 0.013). Duration of surgery, estimated blood loss and need for blood transfusion were similar between both groups (p > 0.05). Postoperative oral feeding initiation time was significantly earlier in the CSEA group (1 day and 3 days, p < 0.001). Visual Analog Scale (VAS) scores were significantly lower in the CSEA group (3.0 vs. 4.6, p = 0.004). The number of lymph node removals was significantly higher in the CSEA group (28.80 ± 7.77 vs. 12.90 ± 7.13, p < 0.001). Locally advanced disease rate was more common in the CSEA group (80% vs. 20%, p < 0.010). However, Clavien-Dindo Grade ≥ III complication rates and length of hospitalization were similar between the groups (p > 0.05). CONCLUSIONS: Open RC under CSEA is a preferable option for elderly patients and those with comorbidities who are not suitable for general anaesthesia. It offers advantages in postoperative bowel function recovery and pain management compared with general anaesthesia. TRIAL REGISTRATION: retrospectively registered.