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Cost Savings of Patient-Controlled Intrathecal Analgesia

To the Editor: With great interest, we read the recent article by Winer et al comparing influences of epidural versus intravenous patient-controlled analgesia on outcomes after radical cystectomy in a retrospective cohort study. They showed that, despite significant improvements in initial postoperative pain control and less opioid requirement with patient-controlled epidural analgesia, there was no association between 2 analgesic methods in the length of stay, return of bowel function, or postoperative complications. In our view, certain issues in addition to the limitations described may have confounded interpretation of the study’s findings. First, the age of patients in this study ranged from 59 to 74 years. We would like to know whether comorbidities in addition to diabetes were comparable between the 2 groups, particularly cardiovascular and pulmonary comorbidities. It has been shown that baseline comorbidity status is associated with increased postoperative complications, prolonged length of stay, and perioperative mortality in patients undergoing radical cystectomy. Furthermore, in elderly patients with radical cystectomy, impaired preoperative cardiopulmonary reserve is closely related to postoperative major morbidity, prolonged length of hospital stay, and increased use of critical care resource. Second, preoperative hemoglobin and albumin levels were not included in the demographic data of patients. Actually, preoperative anemia caused by hematuria that results from bladder cancer is highly prevalent in patients undergoing radical cystectomy, with an incidence of 75%. In patients with noncardiac surgery, even mild degrees of preoperative anemia have been associated with an increased risk of postoperative mortality and morbidity. Furthermore, hypoalbuminemia is another common problem in patients with cancer. In patients undergoing radical cystectomy, preoperative hypoalbuminemia (<3.5 g/dL) has been identified as an independent predictor of postoperative complications and mortality when controlling for sex, race, ageadjusted Charlson score, body mass index,