A Randomized Study of the Efficacy of Low Venous Pressure General Anesthesia Versus Combined Spinal-Epidural Anesthesia in Decreasing Blood Loss During Prostate Surgery

This is a prospective randomized trial comparing the efficacy of a low venous pressure general anesthesia (LVPGA) technique vs. combined spinal-epidural anesthesia (CSE) in decreasing intraoperative blood loss in patients undergoing open radical retropubic prostatectomy (RRP) for newly diagnosed clinically localized adenocarcinoma of the prostate. The study design involves the enrollment of 246 patients scheduled for RRP. To control for surgeon technique in the varibility of intraoperative blood loss, the study will be limited to the patient population of two surgeons who perform greater than 150 radical prostatectomies per year. Patients will be stratified for each surgeon and will be randomized to receive either a LVPGA or CSE. Preoperatively patients will be encouraged to donate autologous blood as is the current practice at MSKCC. Perioperative measurement and management of fluid administration, estimation of blood loss and urine output, and transfusion criteria will be standardized for both anesthesia groups. Transfusion of blood products will be at the discretion of the attending surgeon and anesthesiologist following the guidelines described in the protocol. Autologous blood will not routinely be transfused back if the hemoglobin is >= 8.0 and the patient is not symptomatic. Patients randomized to the CSE arm will also receive postoperative epidural analgesia, while patients randomized to LVPGA will receive intravenous PCA analgesia as per our current standard of care. Pain relief will be assessed by a standardized pain scale and recorded in the PACU and then twice daily until discharge. All patients will receive routine preoperative evaluation, as well as routine intraoperative and postoperative monitoring and care. All patients will be placed on a routine postoperative pathway. The MSKCC Morbidity/Mortality DMT Documentation System will be utilized to document postoperative complications as per our routine practice. The Surgical Secondary Events (SSE) program is designed to provide risk adjusted postoperative morbidity and mortality data for institutional comparisons and as a decision support project, generating, reporting and analyzing events to promote change and improvement in patient management. SSE are grouped in 6 grades depending on the severity of the complication and the treatment requirements: Grade 0, no event observed beyond 30 days postop. Grade 1, use of oral medications, bedside interventions to treat an event. Grade 2, use of I.V. medications, TPN, enteral nutrition, or blood transfusion to treat an event. Grade 3, interventional radiology, therapeutic endoscopy, intubation, angiography or operation required to treat an event. Grade 4, residual and lasting disability requiring major rehabilitation or organ resection. Grade 5, event resulting in death of patient.

Inclusion criteria

• They are scheduled for RRP by Drs. Scardino or Eastham.
• They speak English in order to cooperate during CSE if randomized to such arm.
• They have clinically localized disease, clinical stage < cT3NxM0 (1997 TNM), any Gleason grade
• Must be willing to receive blood products or blood if deemed clinically necessary
• Must be willing to receive epidural or general anesthesia
• All subjects must be age 18 or older
• Patient or the patient's legally acceptable representative must sign and date informed consent PRIOR to any study related procedures being performed.
• Patient must have an MRI of the prostate done at MSKCC prior to RRP.

Exclusion criteria

• Prior history of significant cardiac disease (defined as unstable angina, coronary artery stent placement within 8 weeks of surgery, MI within 6 months of surgery, known history of cardiomyopathy, congestive heart failure or significant valvular heart disease), insulin dependent diabetes mellitus, or clinically significant carotid artery disease.
• Presence of renal insufficiency (define by creatinine level > 1.6 mg/dl).
• Prior radiation therapy to the pelvis or prostate
• History of bleeding tendencies, hemorrhagic diathesis, or known primary or secondary hematological disease such as chronic renal failure, Von Willebrand disease, and thrombocytopenia among others.
• History of lumbar spine disease or peripheral neurological conditions that may contraindicate use of CSE anesthesia.
• Prior transurethral resection of the prostate or a suprapubic prostatectomy
• Prior history of an abdominal perineal resection or local excision of a colorectal cancer
• Patients requiring anticoagulation due to a pre-existing medical illness or increased risk for thromboembolic events such as prior history of pulmonary embolus, morbid obesity, atrial fibrillation, mechanical heart valve, etc.
• History of morphine allergy
• History of fentanyl allergy
• History of allergy to local anesthetics