INTRODUCTION AND METHODS
With the growing life expectancy of the western population, an increasing number of patients older than eighty years present with muscle invasive bladder cancer. Radical cystectomy with pelvic lymphadenectomy and urinary diversion is the standard of care for both high-risk non-muscle-invasive and muscle-invasive bladder cancer. Robot-assisted minimally invasive procedures have already proven to reduce peri-operative morbidity, what is most important in the elderly.
However, only 14% of the octogenarians receive this kind of treatment. Conversely, this figure is 49.4% in the age group 65-79 years. This discrepancy is likely related to the fear of perioperative morbidity and mortality when performing radical cystectomy in the very elderly. With this retrospective evaluation of the charts of 155 consecutive patients, who underwent robot-assisted radical cystectomy (RARC) for muscle-invasive or high-risk non-muscle invasive urothelial carcinoma of the bladder between 2003 and 2014 at a high-volume robotic center, we evaluated whether this fear is justified. Specifically we retrospectively evaluated the perioperative morbidity and mortality, 3-year recurrence-free survival and cancer-specific mortality in patients older than 80 years undergoing RARC.
RESULTS AND DISCUSSION
Of 155 consecutive patients, 22 (14,2%) patients were 80 years or older. Candidates who were fit for surgery were carefully selected at the discretion of the surgeon and anesthesiologist. Consequently, ASA-score (p=0.4) and Charlson comorbidity index (p=0.4) were similar in younger and older patients. Prevalence of any grade and high-grade complications was similar in both groups (all p≥0.6). No perioperative mortality was recorded within 90 days from surgery. Older patients had significantly higher pathological tumor grade (p=0.04) and a lower use of pelvic lymphadenectomy (p<0.001). Elderly patients had a similar risk of 3-year oncological recurrence after surgery as compared to their younger counterparts (OR 1.63; p=0.2). Conversely, the risk of cancer-specific mortality was significantly higher (OR 2.78; p=0.02). This maybe can be explained by the significant higher pathological tumor stage in elderly patients at one side and by the lower use of pelvic lymphadenectomy in these patients on the other side. The lower use of pelvic lymphadenectomy in octogenarians in this series is mainly the result of a multidisciplinary discussion between urologists, anesthesiologists and patients. The aim of not performing the pelvic lymphadenectomy was to lower the perioperative morbitity and to shorten the operative time in this assumed fragile patient population. With regard to the perioperative results of octogenarians in this series, the underuse of pelvic lymphadenectomy in the very elderly might be reconsidered in the near future.
We found that in carefully selected elderly patients undergoing RARC for both high-risk, non-muscle-invasive and muscle-invasive bladder cancer, peri- and post-operative morbidity and mortality, and 3-year recurrence-free survival rates were similar when compared to younger patients. Therefore, age by itself can’t be the only consideration for the indication for RARC in the very elderly. RARC can be safely performed in selected elderly patients by experienced surgeons
Ruben De Groote1, Giorgio Gandaglia1,2,3, Nicolas Geurts1, Marijn Goossens1, Elisabeth Pauwels1, Frederiek D’Hondt1, Christian Gratzke4, Geert De Naeyer1, Peter Schatteman1, Paul Carpentier1, Giacomo Novara2,5, Alexandre Mottrie1,2
Department of Urology, O.L.V. Hospital, Aalst, Belgium
O.L.V. Vattikuti Robotic Surgery Institute, Melle, Belgium
Division of Oncology/Unit of Urology; URI; IRCCS Ospedale San Raffaele, Milan, Italy
Urologische Klinik und Poliklinik, Klinikum der Universität München, Ludwig-
Maximilians Universität München, Munich, Germany
Department of Surgery, Oncology, and Gastroenterology - Urology Clinic University of Padua, Italy