A randomized controlled trial investigating rectus sheath catheters following radical cystectomy.

Abstract

The use of thoracic epidural (TE) for postoperative analgesia has been the standard of care following radical cystectomy (RC). The use of rectus sheath catheters (RSC) has also been reported. We evaluated whether RSCs may be an alternative to TEs. In a non-blinded, single center, non-inferiority study, patients undergoing open RC were randomized 1:1 to receive either a TE or surgically placed RSC. The primary endpoint was the cumulative opiate use (median oral morphine equivalent (OME)) in the first 72 hours post-operatively. Secondary outcomes included visual analogue pain scores (VAS), measures of post-operative recovery including mobility, time to diet, and complications. Ninety-seven patients were randomized (51 TE, 46 RSC). The median OME was 103mg (77.5-132.5) in the TE arm and 161.75mg (117.5-187.5) in the RSC arm. The Mann-Whitney U test confirmed non-inferiority of RSC to TE at a threshold of 15mg OME (P=0.002). When comparing pain scores for the first three postoperative days, an early difference was seen that favoured the TE group during post-anesthesia care unit stay which was lost after postoperative day one. Patient satisfaction with analgesia on the third postoperative day was similar in both arms (P=0.47). There were no statistically significant differences between arms with respect to the other secondary outcomes. The outcomes from this prospective randomized trial have demonstrated non-inferiority of RSC compared to TE with respect to 72-hour opiate use. Patient satisfaction with pain control on post-operative day 3 was the same for each group.