Increased One-Year Mortality Among Elderly Patients After Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Retrospective, Observational Comparative Study

Abstract

Introduction Muscle invasive bladder cancer (MIBC) is a common malignancy amongst elderly. Increasing life expectancy, prevalence of smoking, lifelong exposure to environmental pollutants and immunosenescence contribute to growing number of cases. Traditionally, radical cystectomy (RC) with pelvic lymph node dissection (PLND) constituted the mainstay of treatment for MIBC, but despite proven feasibility in elderly population, it has been associated with significant burden of morbidity, mortality, and complications. Study Objective We aimed to re-evaluate the safety and efficacy of RC amongst the elderly patients with MIBC. Material and Methods This single-center, retrospective, observational comparative study was conducted among 568 patients who underwent RC due to MIBC between 2003 and 2021. We evaluated the influence of chronological age (<70 vs ≥70 years) on clinical, demographic, and pathological variables related to MIBC and RC. Results Elderly patients had similar clinical and pathological features of disease compared to their younger counterparts; nonetheless, they more often received simplified urinary diversion, ie ureterostomy (60.25% vs 39.33%, p<0.001) and had no PLND (15.76% vs 8.5%, p=0.01) during RC. Furthermore, more elderly patients were treated for secondary MIBCs and fewer had history of smoking. Severe complication and 90-day mortality rates were comparable between groups; however, the elderly had significantly higher all-cause mortality at one year post RC (46.67% vs 33.25%, p=0.003). On multivariate analysis, one-year mortality risk was independently associated with elderly age (HR=2.119, 95% CI: 1.227–3.660, p=0.007), rural residency (HR=1.760, 95% CI: 1.043–2.968, p=0.034), extravesical extension of tumor (HR=2.109, 95% CI: 1.155–3.850, p=0.015), lymph node metastasis (HR=2.268, 95% CI: 1.290–3.987, p=0.004) and omission of PLND (HR=6.064, 95% CI: 2.926–12.568, p<0.001). Conclusion Radical cystectomy in elderly patients is associated with significant one-year mortality. Our study emphasizes the unmet need for considerate planning of treatment for MIBC in potentially vulnerable groups of elderly patients. Efforts are needed to reliably identify those unlikely to benefit from surgery and facilitate patient-centered choice of alternative therapies.

Twenty-Four-Month Efficacy of Ureteroureterostomy Combined With Unilateral Nephrostomy Following Radical Cystectomy

“…The causes of death of the above-mentioned patients are not anastomosis related but mainly the progression of the disease and natural causes due to the advanced age of the sample. Lemiński et al and Aziz et al studies confirm our findings, as older age is documented as an independent factor for increased all-cause mortality among patients with muscle-invasive BC undergoing radical cystectomy [7,8].…”

Combined Modality Bladder-Sparing Therapy for Muscle-Invasive Bladder Cancer: How (Should) We Do It? A Narrative Review

“…Moreover, the increasing life expectancy and aging of Western societies have led to a higher proportion of elderly patients with MIBC, which, given their increased comorbidity and risk of frailty, makes surgery an even more challenging choice [ 13 ]. Although advances in surgical techniques and perioperative care allow most of the elderly to undergo RC with acceptable perioperative risks, a substantial proportion of these patients eventually die within a year of the surgery [ 14 ]. Consequently, in progressively aging populations, there is a growing number of patients with MIBC who are considered unfit for RC.…”

Immunotherapy and radiotherapy for older patients with invasive bladder cancer unfit for surgery or chemotherapy: practical proposal by the international geriatric radiotherapy group

“…Among patients with invasive bladder cancer who underwent radical cystectomy. the mortality rate was significantly higher in older patients one year after the procedure ( 4 ). Frailty prior to surgical resection is often prognostic of a high mortality rate after treatment ( 5 ).…”