SIU 2018: MRI Should Be Performed in All Patients Before Biopsy: Bladder Sparing Surgery – CON

Seoul, South-Korea (UroToday.com) This session began with a case presentation of a 76-year-old man with muscle-invasive bladder cancer (MIBC). This was a generally healthy man with mild hypertension, who had macroscopic painless hematuria, and was diagnosed with MIBC after transurethral resection of a bladder tumor (TURBT). Badrinath Konety, MD presented his point of view, on why this patient should undergo radical cystectomy, which is the gold standard treatment for a patient with MIBC.

Dr. Konety began his talk showing data from a large population-based database from across the US. The data showed that the factors that influence aggressive therapy for bladder cancer include the patient’s age, race, gender, disease stage, and the geographical location of the patient.1 The percentage of T2 (muscle-invasive disease) significantly rises with age, with less than 2% of patients younger than 35 harboring  MIBC,  to approximately 15% of patients older than 85 having it. However, the rate of radical cystectomy in the elderly patients throughout the last decade has been not higher than 15% of these patients. 2

When specifically looking at these elderly patients who do undergo radical cystectomy in the US, most are treated at low/intermediate volume hospitals.2 The inpatient mortality is about twice as high in these patients, and adverse perioperative outcomes are more frequent. Such patients may benefit from radical cystectomy at high volume and academic centers to maximally reduce adverse perioperative outcomes. When comparing outcomes of patients undergoing radical cystectomy at different age groups, the 90-day mortality rate is worse in elderly patients than in younger patients, while major and minor complications are the same in all age groups.3

Next, Dr. Konety began to compare the possible treatments available for the presented patient. These include treatments either in the form of radical cystectomy, or bladder-sparing treatment, better known as trimodal therapy, consisting of maximal TURBT, radiotherapy, and chemotherapy.  When comparing the costs of these two treatment alternatives, the cost is significantly higher in the bladder sparing group. 4

Another factor that is important not to overlook is the frailty index, which is based on functional status, history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension.5 This index has been shown to predict the rate of complications following radical cystectomy. As the frailty index increases, the risk of complications increases as well. With a frailty index of 1, the hazard ratio for a complication is 1.17, while if the frailty index is 3 points or more, the hazard ratio is 3.22. The overall complication rate has been shown to be 11.7%, and the mortality is 1.6% in patients older than 65 undergoing radical cystectomy. 5

In summary, radical cystectomy is overall a safe and feasible procedure in the elderly. It is important that surgeons assess the biological age of the patient and not the chronological age. This can be assessed using the frailty index, which is a far more accurate method of assessing the patient’s status than to simply rely on age. Elderly patients require a comprehensive geriatric assessment before surgery. Additionally, they need an adequate rehabilitation support system and caregiver assistance.

 
Presented by: Badrinath Konety, MD, University of Minnesota, United States

References:
1. Konety BR et al. J Urol 2003
2. Roghman F  et al. Urol Int 2014
3. Fontaine V et al. Eur Urol 2018
4. Svatek R et al. Eur Urol 2014
5. Sathianathen NJ et al. Eur Urol 2018 

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre  Twitter: @GoldbergHanan at the 38th Congress of the Society of International Urology - October 4- 7, 2018 - Seoul, South Korea

Further Related Content: 
MRI Should Be Performed in All Patients Before Biopsy: Bladder Sparing Surgery – PRO
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