Open Radical Cystectomy Under Combined Spinal-Thoracic Epidural Anesthesia in High-Risk Patients: A Multicenter Retrospective Cohort Study

Background/Objectives: To evaluate the feasibility, in-hospital mortality, and perioperative morbidity of open radical cystectomy performed entirely under combined spinal-thoracic epidural anesthesia (CSTEA) in patients with a predominantly high anesthetic risk profile. Methods: This retrospective multicenter cohort study included 145 consecutive adults with histologically confirmed bladder cancer who underwent open radical cystectomy with pelvic lymph node dissection and urinary diversion under planned CSTEA at two institutions between 2008 and 2017. The rationale for CSTEA was to preserve spontaneous breathing and avoid planned intubation and neuromuscular blockade in selected patients. The primary endpoint was in-hospital mortality during the index admission. Results: Most patients were classified as American Society of Anesthesiologists (ASA) III (85.5%) or ASA IV (1.4%). Urinary diversion consisted of transureteroureterocutaneostomy in 97 patients (66.9%), ileal conduit in 24 (16.6%), and orthotopic ileal neobladder in 24 (16.6%). No patient required intraoperative conversion to general anesthesia. In-hospital mortality was 0.7% (1/145), and severe complications occurred in 5.5%. Median length of stay was 15 days, and median postoperative pain score was 1. Conclusions: Open radical cystectomy under CSTEA appeared feasible in selected patients and was associated with low in-hospital mortality, low severe complication rates, and favorable early recovery. These findings support CSTEA as a feasibility-based option in experienced centers, while prospective comparative studies using standardized in-hospital, 30-day, and 90-day endpoints are needed.