Regional Anesthesia for Open Radical Cystectomy: An Interesting Alternative, but for Whom? Comment on Peich et al. Open Radical Cystectomy Under Combined Spinal-Thoracic Epidural Anesthesia in High-Risk Patients: A Multicenter Retrospective Cohort Study. Soc. Int. Urol. J. 2026, 7, 32

In the current issue of Société Internationale d’Urologie Journal, Peich et al. reported the outcomes from the largest open radical cystectomy series under combined spinal–thoracic epidural anesthesia in high-risk surgical candidates [1]. This study included 145 patients from two institutions: one from Germany and one from Ukraine. The majority of patients were either American Society of Anesthesiologists (ASA) III or ASA IV. The most frequently performed urinary diversion was transuretero-ureterocutaneostomy which was performed in 97 patients (67%) while the remaining patients underwent either ileal conduit (24 cases; 17%) or orthotopic ileal neobladder (24 cases; 17%). No patients required conversion to general anesthesia, but a great majority (75%) required intraoperative sedation with intravenous propofol. Severe (Clavien Dindo grade III or IV) complications occurred in only 5.5% of cases and in-hospital mortality occurred in only one case (1/145; 0.7%).

Significant comorbidities are common in patients who underwent radical cystectomy for bladder cancer; frailty and performance status remains the most important risk for severe surgical complications and mortality [2]. Therefore, strategies aimed at reducing perioperative physiological stress deserve careful investigation. Open radical cystectomy under combined spinal–thoracic epidural anesthesia is an intriguing surgical solution in patients who would not tolerate a long duration general anesthesia. Thus, the outcomes of the study by Peich et al. are an important contribution to the literature and authors should be commended for reporting the largest series to date evaluating this approach. Although these outcomes seem very promising, discretion is required to evaluate these outcomes. Importantly, the predominance of transuretero-ureterocutaneostomy (particularly in the Ukrainian cohort) likely contributed substantially to the relatively short operative times and favorable perioperative outcomes observed in this study. These findings cannot be readily generalized to contemporary bowel-based urinary diversions, such as ileal conduits and orthotopic neobladders, as outcomes for these subgroups were not reported separately. In fact, the only diversion-specific finding was a higher complication burden among patients undergoing bowel-involving urinary diversions. Without the data regarding the 30-day and 90-day mortality rates, definitive conclusions regarding the safety of this technique should be avoided. Furthermore, we cannot claim better safety profiles for open radical cystectomy under regional anesthesia compared to general anesthesia since there is no comparative arm in this study. However, a previous study reported shorter surgery time and postoperative pain score but similar bowel recovery, postoperative outcomes and 90-day complication rates after combined spinal and epidural anesthesia, compared with open radical cystectomy [3]. Further prospective comparative studies are required to determine whether regional anesthesia offers meaningful advantages over conventional general anesthesia in high-risk surgical candidates.

In anesthetic high-risk patients with Bacillus Calmette-Guérin (BCG) unresponsive disease and/or muscle-invasive bladder cancer, trimodality treatment (TMT) can be a less-invasive and safe solution [4]. The oncological outcomes of TMT have consistently been reported to be comparable to those of radical cystectomy in carefully selected patients [5]. Such an alternative significantly restricts the clinically relevant population in which open radical cystectomy under regional anesthesia can be considered. However, palliative or salvage surgery is required due to refractory bleeding, pelvic pain, fistula formation, unresolving hydronephrosis, or persistent urinary symptoms in patients who experienced recurrence or progression despite TMT [6]. The clinical benefit can be more pronounced for open radical cystectomy under combined spinal–thoracic epidural anesthesia in this specific group of patients.

In conclusion, the study by Peich et al. provides valuable preliminary evidence supporting the feasibility of radical cystectomy under combined spinal–thoracic epidural anesthesia and can be performed with acceptable perioperative outcomes in carefully selected patients. However, given the majority of contemporary radical cystectomies involve bowel-based urinary diversions and prolonged operative times, the generalizability of these findings remains uncertain. While regional anesthesia may represent an attractive option for select frail patients who are poor candidates for general anesthesia, further prospective studies are needed to determine whether this approach offers clinically meaningful advantages over current standards of care.