Bupivacaine Local Anesthetic to Decrease Opioid Requirements after Radical Cystectomy: Does Formulation Matter?

Introduction: Reduction of opioids is an important goal in the care of patients undergoing radical cystectomy (RC). Liposomal bupivacaine (LB) has been shown to be a safe and effective pain reliever in the immediate postoperative period and has been reported to reduce postoperative opioid requirements. Since the liposomal formulation is predicated on slow systemic absorption, the amount of bupivacaine administered is notably higher than that typically used with standard bupivacaine (SB) formulations. In addition, LB is costly, not universally available, and studies comparing this formulation to SB are lacking. We sought to determine if there is a difference in postoperative opioid requirements in patients who receive LB vs. high dose SB at the time of RC. Methods: In May 2019 we transitioned to administration of high-volume SB injected intraoperatively at the time of RC. This prospective cohort was compared to a historical cohort of patients who received injection of LB at the time of surgery. Primary endpoints included postsurgical opioid use measured in morphine equivalent dose (MED) and patient-reported Numeric Rating Scale (NRS) pain scores and length of stay. All patients were managed using principles of enhanced recovery after surgery (ERAS). Results: From May 2019 through August 2019, 28 patients underwent RC and met eligibility criteria to receive SB at the time of surgery. They were compared to a historical cohort of 34 patients who received LB between November 2017 and July 2018. There was no difference in MED exposure either in the postanesthesia care unit (SB 9.0 +/- 8.9 MED vs. LB 6.5 +/- 9.4 MED, P= 0.29) or during the remainder of the hospital stay (SB 36.8 +/- 56.9 MED vs. LB 42.1 +/- 102.5 MED, P= 0.81), no difference in NRS pain scores on postoperative day 1 (SB 2.6 +/- 1.6 vs. LB 2.1 +/- 1.7, P= 0.23), day 2 (SB 2.4 +/- 1.8 vs. LB 1.9 +/- 1.6, P= 0.19), or day 3 (SB 1.9 +/- 1.8 vs. LB 1.7 +/- 1.7, P= 0.69) and no difference in length of stay (SB 5.0 +/- 1.7 days, LB 4.9 +/- 3.3 days, P= 0.93). Subgroup analysis of open RC and robotic-assisted RC showed no significant difference in MED or pain scores between LB and SB patients. Conclusions: Among patients undergoing RC under ERAS protocol there was no significant difference in postoperative opioid consumption, NRS pain scores, or length of stay among patients receiving SB compared to LB. (C) 2020 Elsevier Inc. All rights reserved.