Age and comorbidity impact surgical therapy in older bladder carcinoma patients

Elderly and bladder cancer: The role of radical cystectomy and orthotopic urinary diversion

The incidence of bladder cancer (BC) depends on advancing age and other risk factors, significantly impacting on surgical, functional and oncological outcomes. Radical cystectomy (RC) with urinary diversion is the gold standard therapy for muscle invasive bladder cancer; however, it remains a complex surgery and requires careful analysis of risk factors in order to potentially decrease post-surgical complication rates. Age in surgery is a limiting factor that can modify surgical and oncological outcomes, and is correlated with a high rate of post-dimssion hospital readmissions. The reconstruction of the bladder with the intestine represents a crucial point of radical cystectomy and the urinary derivation (UD) is at the center of many debates. A non-continent UD seems to be the best choice in elderly patients (>75 years old), while orthotopic neobladder (ON) is poorly practiced. We reviewed the literature to identify studies reporting outcomes, complications, patient- selection criteria, and quality-of-life data on elderly patients, who underwent ON following radical cystectomy. Reviewing the literature there is no clear evidence on the use of age as an exclusion criterion. Certainly, the elderly patient with multiple comorbidities is not eligible for ON, preferring other UD or rescue therapies. A careful preoperative selection of elderly patients could greatly improve clinical, surgical and oncological outcomes, giving the chance to selected patients to receive an ON.

Geriatric anesthesia: Demographics, epidemiology, state of the art at international level, educational needs, and future perspectives

Population aging has induced in the last year a corresponding aging inside the surgical population, currently accounting for 45%.50% of the total surgical population in the majority of the advanced countries. This has induced a number of new challenges in the daily anesthesia practice, ranging from the need of implementing specific education in the field of geriatric medicine, organizational adjustments aimed to adapt our preoperative evaluation methodology to the needs older patients present, and a careful redesign of the whole perioperative course for these patients. Today's anesthesiologists are called to became familiar with the aging processes and their impact on the patho.physiological perioperative course, with the concept of functional impairment and frailty and with the dimensions of polypathology, polymedication, and reduced functional reserves. The introduction of new trends such as the team-based approach and interdisciplinary culture are essential to overcome these emerging criticalities.

Age represents the main driver of surgical decision making in patients candidate to radical cystectomy

BACKGROUND AND OBJECTIVES

Age might influence the choice of surgical approach, type of urinary diversion (UD) and lymph node dissection (LND) in patients candidate to radical cystectomy (RC) for urothelial bladder cancer (UBC). Similarly, age may enhance surgical morbidity and worsen perioperative outcomes. We tested the impact of age (octogenarian vs. younger patients) on surgical decision making and peri- and postoperative outcomes of RC.

METHODS

Non-metastatic muscle-invasive UBC patients treated with RC at 18 high-volume European institutions between 2006 and 2021 were identified and stratified according to age (≥80 vs. <80 years). Intraoperative Complications Assessment and Reporting with Universal Standards and European Association of Urology guidelines recommendations were accomplished in collection and reporting of, respectively, intraoperative and postoperative complications. Multivariable logistic regression models (MVA) tested the impact of age on outcomes of interest. Sensitivity analyses after 1:3 propensity score matching were performed.

RESULTS

Of 1955 overall patients, 251 (13%) were ≥80-year-old. Minimally invasive RC was performed in 18% and 40% of octogenarian and younger patients, respectively (p < 0.001). UD without bowel manipulation (ureterocutaneostomy, UCS) was performed in 31% and 7% of octogenarian and younger patients (p < 0.001). LND was delivered to 81% and 93% of octogenarian and younger patients (p < 0.001). At MVA, age ≥80 years independently predicted open approach (odds ratio [OR]: 1.55), UCS (OR: 3.70), and omission of LND (OR: 0.41; all p ≤ 0.02). Compared to their younger counterparts, octogenarian patients experienced higher rates of intraoperative (8% vs. 4%, p = 0.04) but not of postoperative complications (64% vs. 61%, p = 0.07). At MVA, age ≥80 years was not an independent predictor of length of stay, intraoperative or postoperative transfusions and complications, and readmissions (all p values >0.1). These results were replicated in sensitivity analyses.

CONCLUSIONS

Age ≥80 years does not independently portend worse surgical outcomes for RC. However, octogenarians are unreasonably more likely to receive open approach and UCS diversion, and less likely to undergo LND.

Beta-blocker use and urothelial bladder cancer survival: a Swedish register-based cohort study

BACKGROUND

Recent observational studies linked β-adrenergic receptor blocker use with improved survival in patients with several cancer types, but there is no information on the potential effects of β-blockers in patients with bladder cancer. Literature from pre-clinical studies is also limited, but urothelial cancer can exhibit significant overexpression of β-adrenergic receptors relative to normal urothelial tissue, suggesting that urothelial cancer may benefit from β-blockade therapy. We thus aimed to explore the possible association between β-blocker use and bladder cancer-specific mortality (BCSM) among patients with urothelial bladder cancer.

MATERIAL AND METHODS

Patients diagnosed during 2006-2014 and identified from the Swedish Cancer Register (n = 16,669) were followed until 31 December 2015. Cox regression was used to evaluate the association of β-blockers dispensed within 90 days prior to cancer diagnosis with BCSM (primary outcome) and all-cause mortality, while controlling for socio-demographic factors, tumor characteristics, comorbidity, other medications and surgical procedures. Hazard ratios (HR) with 95% confidence intervals (CI) were reported.

RESULTS

Overall, β-blocker use was associated with lower BCSM [HR 0.88 (95%CI 0.81-0.96)]. Especially use of nonselective β-blockers showed a clear inverse association in comparison with both nonuse [0.66 (0.50-0.86)] and use of other antihypertensive medications [0.72 (0.54-0.95)]. The inverse association was most pronounced among patients with locally advanced/metastatic disease: [0.35 (0.18-0.68)]. A lower-magnitude inverse association was observed for selective β-blocker use [0.91 (0.83-0.99)]. Largely similar inverse associations were observed for hydrophilic [0.82 (0.70-0.95)] and lipophilic [0.91 (0.83-1.00)] β-blocker use.

CONCLUSION

β-blocker use, particularly of the nonselective type, was associated with lower BCSM, especially in patients with locally advanced/metastatic urothelial bladder cancer.

Patterns of treatment in older patients with newly diagnosed advanced bladder cancer: A SEER dataset analysis

Background

Bladder cancer is one of the top 10 cancers diagnosed in Americans with a median age of 73. This is the patient population that tends to be older with multiple medical conditions, and previously described variability in treatment in the earlier stages of the disease. This study aimed to evaluate the first-line therapeutic choices for older adults newly diagnosed with advanced bladder cancer. In addition, this work evaluated predictors of response as well as the role of events of functional importance in relation to treatment assignment.

Methods

A population-based cohort study was conducted using the SEER-Medicare database of patients with advanced stage bladder cancer not eligible for curative intent therapy between 2010 and 2013. Patient groups of interest were compared via univariate and multivariate associations. Additionally, a latent class analysis was applied to identify classes with similar features in reference to events of functional importance-events linked to the maintenance or improvement of physical function status.

Results

Within the sample, we noted that a minority of patients received a standard cisplatin-containing regimen (14.77%) and a majority did not receive any chemotherapy (59.69%). Most patients were over age 75. The adjusted odds ratio of no chemo versus cisplatin in patients aged 76 and older compared to patients 66-75 was 6.61 (4.79-9.13; p < 0.0001). We applied latent class analysis methods to the dataset, and three classes demonstrated very low and moderate levels of functional events in the 12 months prior to a person's first outpatient visit for advanced bladder cancer care.

Conclusions

Patients with new diagnosis of advanced bladder cancer largely do not receive the recommended first-line systemic therapy of cisplatin chemotherapy, and a significant majority does not receive any treatment. When evaluating the association between class assignment and predictors of chemotherapy use, such as comorbidity and age, patients with "low usage overall" were more likely to receive chemotherapy. Yet even patients who received chemotherapy had some events of functional importance.

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

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.

Comparative Study of Perioperative and Oncological Outcomes Between Elderly Patients and Younger Patients Who Received Radical Cystectomy and Pelvic Lymph Node Dissection: A Single-Center Retrospective Study

PURPOSE

To compare the perioperative and survival outcomes of patients over 75 years and younger patients who received radical cystectomy.

PATIENTS AND METHODS

A total of 119 patients aged ≥75 years and 488 patients aged <75 years were enrolled. All patients underwent radical cystectomy with pelvic lymph node dissection. Clinical characteristics and perioperative outcomes were compared between the two groups. Overall survival and progression-free survival were analyzed by using the Kaplan-Meier method. Cox regression analysis and logistic regression analysis were used to identify the risk factors affecting the outcomes observed.

RESULTS

There was no significant difference in perioperative complications between the elderly patient group and the younger patient group (p = 0.349). The 5-year overall survival of elderly patients was lower than that of young patients (p < 0.001). Age ≥75 years was a risk factor for overall survival (HR = 1.69 [95% CI: 1.22-2.35]; p = 0.002) and progression-free survival (HR = 1.69 [95% CI: 1.14-2.50]; p = 0.008) for patients who received radical cystectomy but was not a poor risk factor for major complications (HR = 1.25 [95% CI: 0.47-3.31]; p = 0.658) after radical cystectomy. In addition, preoperative renal insufficiency was associated with a higher risk of major complications.

CONCLUSION

In our cohort, compared with younger patients, elderly patients aged ≥75 years had worse survival outcomes, but age ≥75 years was not a risk factor for major complications after radical cystectomy with pelvic lymph node dissection. Radical surgery should be encouraged for elderly patients who can tolerate aggressive treatments.

Evaluation of Functional Outcomes and Quality of Life in Elderly Patients (>75 y.o.) Undergoing Minimally Invasive Radical Cystectomy with Single Stoma Ureterocutaneostomy vs. Bricker Intracorporeal Ileal Conduit Urinary Diversion

Background: Diversion after radical cystectomy (RC) is crucial when considering elderly subjects. Data on the quality of life (QoL) impact with different diversions is scarce. This study aims to compare complications and QoL in patients aged > 75 y.o., who underwent minimally invasive (MI) RC with Bricker intracorporeal urinary derivation and single stoma ureterocutaneostomy. Methods: We conducted a retrospective analysis of elderly patients who underwent MIRC and intracorporeal diversion. The 78 subjects were divided into two groups: group A, ileal conduit, and group B, single stoma ureterocutaneostomy. We evaluated the bowel’s recovery time and complications rate. We investigated QoL 3 and 6 months after surgery using the Stoma-QoL questionnaire. Results: Mean age was 77.2 in group A and 82.4 in group B. The mean ASA score and Charlson Comorbidity index were comparable between the two groups. Rates of complications were 57.6% and 37.4% in groups A and B, respectively. The mean postoperative Stoma-QoL score 3 months after surgery was 52.2 and 52.4 in groups A and B, respectively. At 6 months of follow-up the Stoma QoL mean score was 63.4, showing homogeneity between the groups. Conclusion: MIRC with single stoma ureterocutaneostomy represents an alternative to ileal conduit, with comparable QoL and ostomy management 6 months after surgery, reporting fewer complications.

Robotic-assisted radical cystectomy is associated with lower perioperative mortality in octogenarians

OBJECTIVES

To compare perioperative outcomes between robotic and open radical cystectomy in octogenarians using real-world data SUBJECTS AND METHODS: Using the Premier Healthcare Database, we found 13,127 patients who underwent robotic-assisted radical cystectomy (RARC) between 2008 and 2017, of which 15.1% were ≥80 years old. Perioperative mortality was the primary outcome of interest. Secondary outcomes include complications, hospital length of stay, readmission rates, and disposition after discharge. Multivariable regression analysis was used to adjust for patient and hospital characteristics.

RESULTS

In octogenarians, mortality at the index admission was 2.2% in those who underwent RARC, compared to 4.6% in those who underwent open surgery (P = 0.027). On multivariable analysis, robotic surgery was associated with lower in-hospital mortality in octogenarians (OR 0.46, 95% CI 0.22-0.99, P = 0.047) even after controlling for patient, and hospital characteristics.

CONCLUSION

RARC is safe and feasible in octogenarians. Elderly patients may derive more benefit from minimally invasive radical cystectomy compared to a younger cohort.

Radical cystectomy and perioperative chemotherapy in octogenarians with bladder cancer

INTRODUCTION

We aimed to compare the treatment patterns and oncological outcomes, including postoperative morbidity and chemotherapy use, between octogenarians and patients <80 years of age who underwent radical cystectomy for bladder cancer.

METHODS

We conducted a retrospective analysis of 119 patients who underwent radical cystectomy for bladder cancer at our center between January 2013 and April 2019. Comorbidities, clinical and pathological data, 30-day postoperative morbidity, and perioperative chemotherapy use were compared between octogenarians (n=31) and younger patients (n=88). Cancer-specific and overall survival rates were estimated with the Kaplan-Meier method and compared between the groups.

RESULTS

No significant differences were found between the age groups in the clinical and pathological findings, including Charlson comorbidity index, modified frailty index, albumin level, renal function, and TNM stage. The median followup for survivors was 19 months (interquartile range [IQR] 11-30). Major complications (Clavien-Dindo grade ≥3) and 30-day postoperative mortality rates did not differ between the age groups (p=0.3 and p=0.18, respectively). Despite no difference in baseline glomerular filtration rates, perioperative chemotherapy utilization rate was lower among octogenarians compared to younger patients (13% vs. 34%, p=0.03). Estimated two-year cancer-specific survival rates for octo-generians and younger patients were 40% and 75%, respectively. Similarly, estimated two-year overall survival rates were 30% and 69%, respectively. Both cancer-specific and overall survival rates were significantly lower in octogenarians (p=0.007 and p=0.001, respectively).

CONCLUSIONS

Radical cystectomy in octogenarians results in comparable short-term outcomes as in younger patients. However, in the elderly population, perioperative chemotherapy utilization rates are lower and survival is inferior.

Association of age with response to preoperative chemotherapy in patients with muscle-invasive bladder cancer

Purpose

To assess the association of patient age with response to preoperative chemotherapy in patients with muscle-invasive bladder cancer (MIBC).

Materials and methods

We analyzed data from 1105 patients with MIBC. Patients age was evaluated as continuous variable and stratified in quartiles. Pathologic objective response (pOR; ypT0-Ta-Tis-T1N0) and pathologic complete response (pCR; ypT0N0), as well survival outcomes were assessed. We used data of 395 patients from The Cancer Genome Atlas (TCGA) to investigate the prevalence of TCGA molecular subtypes and DNA damage repair (DDR) gene alterations according to patient age.

Results

pOR was achieved in 40% of patients. There was no difference in distribution of pOR or pCR between age quartiles. On univariable logistic regression analysis, patient age was not associated with pOR or pCR when evaluated as continuous variables or stratified in quartiles (all p > 0.3). Median follow-up was 18 months (IQR 6–37). On Cox regression and competing risk regression analyses, age was not associated with survival outcomes (all p > 0.05). In the TCGA cohort, patient with age ≤ 60 years has 7% less DDR gene mutations (p = 0.59). We found higher age distribution in patients with luminal (p < 0.001) and luminal infiltrated (p = 0.002) compared to those with luminal papillary subtype.

Conclusions

While younger patients may have less mutational tumor burden, our analysis failed to show an association of age with response to preoperative chemotherapy or survival outcomes. Therefore, the use of preoperative chemotherapy should be considered regardless of patient age.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03793-4.

A comparative study of perioperative and survival outcomes of robot-assisted radical cystectomy in patients over 80 and under 80 years old

Background

Radical cystectomy (RC) is the standard treatment for bladder cancer, but the safety and efficacy of this treatment for elderly people need to be considered. We compare perioperative data and survival outcomes between elderly (≥80 years) and younger (<80 years) patients undergoing robot-assisted radical cystectomy (RARC).

Methods

We reviewed demographic, perioperative clinical and follow-up data of 190 consecutive patients with urothelial carcinoma of bladder who received RARC from May 2015 to December 2018 in Nanjing Drum Tower Hospital. The patients were divided into 2 groups by age: ≥80 years and <80 years. Perioperative outcomes were compared between 2 groups. Logistic regression method was used to analyze the factors that may affect preoperative complications. Cox regression model was employed to analyze the factors affecting 3-year overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS).

Results

Of the 190 patients, 44 (23.2%) were octogenarians. The elderly patients did not statistically differ from younger patients in most of the demographic, perioperative, and pathological information. American Society of Anesthesiologists (ASA) score (p=0.045) and Charlson comorbidity index (CCI) (p=0.035) could predict high-grade and any grade complications, respectively. Positive lymph node and pT≥3 were main factors affecting OS, RFS, and CSS. ASA score (p=0.048) and CCI (p=0.003) could predict OS and RFS, respectively. Elderly group had worse OS (p=0.007) and CSS (p=0.027) but similar RFS (p=0.147) compared with younger group.

Conclusion

The elderly who received RARC had similar risk of perioperative complications and RFS compared with younger patients. RARC could be an alternative treatment for selected octogenarians.

25-Year Trends in Stage-Specific Incidence Rates for Bladder Cancer in a Large Statewide Registry

BACKGROUND: Bladder cancer (BC) is a common genitourinary malignancy with over 80,000 new cases diagnosed annually and over 17,000 associated deaths. OBJECTIVE: We review 25-years of BC incidence (1993-2017) within the state of Pennsylvania to better define incidence, geographic distribution, and trends over time. METHODS: The Pennsylvania Cancer Registry was reviewed for statewide and component county age-adjusted BC incidence rates and stage distribution. Chloropleth maps plotting statewide and county-specific incidence rates across time were created using the GeoDa statistical package. RESULTS: 93,476 cases of BC were recorded in Pennsylvania from 1993 to 2017. Age-adjusted annual rates of BC over the study interval were stable at 24.5 patients per 100,000 (range, 22.7–25.6). However, annual rates of distant disease increased from 0.5 to 1.1 patients per 100,000 (p < 0.001) with an average percent change increase of 6.6% over the study interval. The annual percent distribution of distant disease doubled from 2.3% to 5.1% (p < 0.001) with a greater increase in women compared to men. Chloropleth maps highlighted growing “hot spots” of bladder cancer incidence in the northwestern, northeastern, and southeastern portions of the state. CONCLUSIONS: While BC incidence in the state of Pennsylvania has remained relatively stable over the past 25 years, a concerning increase in distant disease was observed. Geospatial investigation implicates higher risk regions. Further studies are necessary to delineate the underlying etiologies for these observations.

De Ritis ratio: how effectively can we use in bladder cancer management?

Background: This study aims to determine the relationship between the pre-operative De Ritis ratio (DRR) and bladder cancer (BCa) pathological subtypes. Results & methodology: A total of 248 patients with primary BCa were included. Univariate and multivariate analyses were performed to identify whether DRR can be a risk factor for the presence of carcinoma in situ (CIS). There was a statistically significant difference between the nonmuscle invasive BCa risk groups and the muscle-invasive BCa group according to the median DRR levels (p < 0.001). DRR was an independent risk factor for the presence of CIS in multivariate analysis (OR: 1.909; 95% CI: 0.030-0.196; p = 0.008). Discussion & conclusion: DRR can be considered as an independent risk factor for the presence of CIS in patients with primary BCa.

Morbidity and mortality after robot-assisted radical cystectomy with intracorporeal urinary diversion in octogenarians: results from the European Association of Urology Robotic Urology Section Scientific Working Group

Objectives

To evaluate the postoperative complication and mortality rate following laparoscopic radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in octogenarians.

Patients and Methods

We conducted a retrospective analysis comparing postoperative complication and mortality rates depending on age in a consecutive series of 1890 patients who underwent RARC with ICUD for bladder cancer between 2004 and 2018 in 10 European centres. Outcomes of patients aged <80 years and those aged ≥80 years were compared with regard to postoperative complications (Clavien–Dindo grading) and mortality rate. Cancer‐specific mortality (CSM) and other‐cause mortality (OCM) after surgery were calculated using the non‐parametric Aalen‐Johansen estimator.

Results

A total of 1726 patients aged <80 years and 164 aged ≥80 years were included in the analysis. The 30‐ and 90‐day rate for high‐grade (Clavien–Dindo grades III–V) complications were 15% and 21% for patients aged <80 years compared to 11% and 13% for patients aged ≥80 years (P = 0.2 and P = 0.03), respectively. In a multivariable logistic regression analysis adjusting for pre‐ and postoperative variables, age ≥80 years was not an independent predictor of high‐grade complications (odds ratio 0.6, 95% confidence interval 0.3–1.1; P = 0.12). The non‐cancer‐related 90‐day mortality was 2.3% for patients aged ≥80 years and 1.8% for those aged <80 years, respectively (P = 0.7). The estimated 12‐month CSM and OCM rates for those aged <80 years were 8% and 3%, and for those aged ≥80 years, 15% and 8%, respectively (P = 0.009 and P < 0.001).

Conclusions

The minimally invasive approach to RARC with ICUD for bladder cancer in well‐selected elderly patients (aged ≥80 years) achieved a tolerable high‐grade complication rate; the 90‐day postoperative mortality rate was driven by cancer progression and the non‐cancer‐related rate was equivalent to that of patients aged <80 years. However, an increased OCM rate in this elderly group after the first year should be taken into account. These results will support clinicians and patients when balancing cancer‐related vs treatment‐related risks and benefits.

C-reactive Protein/Albumin Ratio and Acute Kidney Injury after Radical Cystectomy among Elderly Patients: A Propensity Score-Matched Analysis

Background

The C-reactive protein (CRP)/albumin ratio is a useful index used to represent patient inflammation and nutritional status. Elderly patients are at the highest risk for acute kidney injury (AKI). We clarified the impact of the preoperative CRP/albumin ratio on AKI and evaluated the impact of postoperative AKI on end-stage renal disease (ESRD) among elderly cystectomy patients.

Methods

We included elderly patients ≥ 65 years of age who underwent radical cystectomy. Multivariate logistic regression analysis and receiver operating characteristic curve analysis were performed to identify risk factors for AKI. Propensity score-matched analysis and conditional logistic regression analysis were performed to elucidate the impact of the CRP/albumin ratio on AKI. The incidence of ESRD was compared between the non-AKI and AKI groups at 12 months after radical cystectomy.

Results

AKI occurred in 110 patients (32.2%). The CRP/albumin ratio and 6% hydroxyethyl starch amount were risk factors for postoperative AKI. The optimal cut-off value for the CRP/albumin ratio predicting AKI was 0.1. After propensity score matching, the AKI incidence in the CRP/albumin ratio ≥ 0.1 group was higher than that in the CRP/albumin ratio < 0.1 group (46.7% vs. 20.6%, P < 0.001), and a CRP/albumin ratio ≥ 0.1 was associated with a higher AKI incidence (odds ratio = 4.111, P < 0.001). The ESRD incidence was higher in the AKI group than in the non-AKI group (7.3% vs. 1.2%, P = 0.017).

Conclusion

A CRP/albumin ratio ≥ 0.1 was associated with an increased incidence of AKI, which was associated with higher ESRD incidence among elderly cystectomy patients.

Genetic variability in 13q33 and 9q34 is linked to aggressiveness patterns and a higher risk of progression of non-muscle-invasive bladder cancer at the time of diagnosis

OBJECTIVE

To identify single nucleotide polymorphisms (SNPs) associated with patterns of aggressiveness of non-muscle-invasive bladder cancer (NMIBC).

PATIENTS AND METHODS

From January 2011 to December 2018, 476 patients with NMIBC were prospectively included. The first step aimed to identify SNPs associated with aggressiveness patterns (e.g. ≥pT1or high-grade/Grade 3 or presence of carcinoma in situ) by analysing the data of a genome-wide association study (GWAS) on 165 patients with BC. The second step aimed to validate the SNPs previously identified, by genotyping the germline DNA of 311 patients with NMIBC.

RESULTS

Overall, the median (interquartile range) age was 66 (58-75) years and the rate of patients with aggressive NMIBC was comparable between both groups (46% vs 46%, P = 1). GWAS data analysis identified four SNPs associated with an aggressive NMIBC (rs12615669, rs4976845, rs2989734, and rs2802288). In the validation cohort, the genotype CC of rs12615669, as well as age >70 years at the time of diagnosis were associated with aggressive NMIBC (P = 0.008 and P < 0.001, respectively). Genotyping of the entire cohort showed an association between aggressive NMIBC and the T allele of rs12615669 (P = 0.0007), the A allele of rs4976845 (P = 0.012), and the A allele of rs2989734 (P = 0.007). A significant association was also found for the entire cohort between the risk of progression and the A allele of rs4976845 (P = 0.04).

CONCLUSION

This two-phase study identified three SNPs (rs12615669, rs4976845, and rs2989734) associated with aggressive NMIBC and one SNP (rs4976845) associated with a higher risk of progression.

Radical cystectomy in a cohort of octogenarians managed in the ERAS era

OBJECTIVES

To describe contemporary perioperative outcomes for octogenarians managed under an Enhanced Recovery After Surgery (ERAS) protocol. ERAS protocols have improved outcomes in radical cystectomy (RC), though outcomes for octogenarian patients undergoing RC in the modern ERAS era are not well researched. ERAS components have been gradually implemented into our clinical care pathways over the past 10 years.

METHODS AND MATERIALS

Octogenarians undergoing RC at our institution were retrospectively identified between 2009 and 2019. Cox proportional hazards models examined changes in time to hospital discharge and time to bowel movement over time, and logistic regression models examined differences in 90-day readmissions and discharge dispositions over time. Secondary analyses examined the effect of alvimopan on time to hospital discharge and time to bowel movement using log-rank tests, along with 90-day readmissions and discharge dispositions using Chi-squared tests.

RESULTS

Seventy octogenarian patients underwent RC during the study period. Median time to bowel movement was 6 days, while median time to hospital discharge was 9 days. Two-thirds of patients were discharged to home and 22% were readmitted within 90 days. There were no statistically significant associations between year of surgery and perioperative outcomes. Patients taking alvimopan had decreased time to hospital discharge (hazard ratio = 2.7, 95% confidence interval [1.5, 5.0], P = 0.002), but showed no difference in other perioperative outcomes.

CONCLUSIONS

Octogenarians treated with RC had no significant changes in perioperative outcomes during the implementation of ERAS components at our institution. However, octogenarians taking alvimopan were observed to have decreased time to hospital discharge.

Bladder preservation in muscle-invasive bladder cancer: a comprehensive review

Background

Standard management of muscle-invasive bladder cancer involves radical cystectomy with pelvic lymph node dissection. However, patients may be ineligible for surgery or may wish to avoid the morbidity of cystectomy due to quality of life concerns. Bladder preservation therapies have emerged as alternatives treatment options that can provide comparable oncologic outcomes while maintaining patients’ quality of life.

Objective

To review bladder preservation therapies, patient selection criteria, and functional and oncologic outcomes for BPT in muscle-invasive bladder cancer.

Materials and Methods

We conducted a comprehensive literature review of bladder preservation therapies in Pubmed and Embase.

Discussion

The ideal patient for BPT has low-volume T2 disease, absence of CIS, absence of hydronephrosis, and a maximal TURBT with regular surveillance. Technological advancements involving cancer staging, TURBT technique, and chemotherapy and radiation therapy regimens have improved BPT outcomes, with oncologic outcomes now comparable to those of radical cystectomy. Advancements in BPT also includes a heightened focus on improving quality of life for patients undergoing bladder preservation. Preservation strategies with most evidence for use include trimodality therapy and partial cystectomy with pelvic lymph node dissection.

Conclusions

This review highlights the breadth of strategies that aim to preserve a patient’s bladder while still optimizing local tumor control and overall survival. Future areas for innovation include the use of predictive biomarkers and implementation of immunotherapy, moving the field towards patient-tailored care.

[Optimizing the management of bladder cancer in older patients]

AIM

To define and present potential improvements for the management of bladder cancer in older patients.

METHOD

Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: bladder cancer, treatment, BCG, chemotherapy, cystectomy, and elderly.

RESULTS

The oncological principles of medico-surgical management of bladder cancer do not differ according to age. On the other hand, the patient comorbidities have been likely to alter the tolerance of these treatments. At the NMIBC stages, no adaptation of the standard treatment has demonstrated any interest. At the MIBC stages, the prognosis was improved by geriatric multidisciplinary perioperative management.

CONCLUSION

The indications and principles of surgical treatments must be identical regardless of the patient age. At the NMIBC stages, adjuvant therapy, including BCG therapy, should not be questioned because of the age of the patient. On the other hand, at the localized MIBC stages, neoadjuvant and adjuvant chemotherapy should not be considered as a standard and their indications assessed individually after geriatric assessment.

A Model for the Prediction of Survival in Patients With Upper Tract Urothelial Carcinoma After Surgery

Objective:

We aimed to formulate and validate prognostic nomograms that can be used to predict the prognosis of patients with upper tract urothelial carcinoma (UTUC).

Methods:

By consulting the Surveillance, Epidemiology, and End Results (SEER) database, we identified patients who were surgically treated for UTUC between 2004 and 2013. Variables were analyzed in both univariate and multivariate analyses. Nomograms were constructed based on independent prognostic factors. The prognostic nomogram models were established and validated internally and externally to determine their ability to predict the survival of patients with UTUC.

Results:

A total of 4990 patients were collected and enrolled in our analyses. Of these, 3327 patients were assigned to the training set and 1663 to the validation set. Nomograms were effectively applied to predict the 3- and 5-year survivals of patients with UTUC after surgery. The nomograms exhibited better accuracy for predicting overall survival (OS) and cancer-specific survival (CSS) than the tumor-node-metastasis (TNM) staging system and the SEER stage in both the training and validation sets. Calibration curves indicated that the nomograms exhibited high correlation to actual observed results for both OS and CSS.

Conclusions:

The nomogram models showed stronger predictive ability than the TNM staging system and the SEER stage. Precise estimates of the prognosis of UTUC might help doctors to make better treatment decisions.

[Epidemiological, pathological and prognostic characteristics of bladder cancer in elderly patients]

AIM

To define and present explanations for the epidemiological, pathological and prognostic differences in bladder cancer in elderly patients.

METHOD

Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: bladder cancer, carcinogenesis, elderly, epidemiology, prognosis.

RESULTS

Bladder cancer is a growing concern for the elderly first and foremost and with an impact, mainly those who are consumers or former users of tobacco, whose therefore frequently have comorbidities associated with this consumption. The initiated carcinogenesis extends with the life length of patients, increasing the prevalence of bladder cancer. Aging promotes carcinogenesis by both potentiating its genetic abnormalities and reducing the immune system performance of the aged host to destroy cancer cells. The delay in the diagnosis of bladder cancer in elderly patients is explained and make up for the time could improve the prognosis.

CONCLUSION

Regardless of variations in therapeutic effect and morbidity and mortality of treatments, aging promotes the occurrence and aggressiveness of bladder cancer. The incentive to stop exposure to carcinogens and the search for bladder cancer in patients with hematuria should not reduce with advanced age but instead be promoted in order to improve the prognosis.

[Organ preservation by chemoradiation for bladder cancer]

When localized, the reference treatment of urothelial, muscle-invasive bladder tumours relies on radical cystectomy with reconstruction by enterocystoplasty if possible or Bricker bypass. Trimodal therapy combining transurethral resection of the tumour followed by concomitant chemotherapy may be considered as a therapeutic alternative to radical cystectomy in well-selected patients with unifocal tumours, stage T2, non-diverticular location, without in situ carcinoma or hydronephrosis and with macroscopically complete transurethral resection. The functional prognosis of the bladder and quality of life should be discussed with the patient as well as the need for salvage surgery for persistent tumour at a 45-Gy dose level, the latter being a highly unfavourable prognosis factor. On the other hand, this trimodal treatment is the reference in case of surgical contraindication. This article details the methods and results of the main series available in the literature in terms of local control, survival, bladder preservation rates and complications, as well as study prospects.

Treatment of Urothelial Cancer in Elderly Patients: Focus on Immune Checkpoint Inhibitors

Urothelial carcinoma, or bladder cancer, is a malignancy that most commonly affects older patients. The median age at diagnosis is 73 years, and care of these patients requires consideration not just of the disease-related factors such as stage and histology, but also of patient-related factors. Many of these patients have concurrent medical morbidities and additional changes related to the aging process. Older patients with cancer are a unique population requiring additional considerations and assessment in treatment decision-making. It is important to look beyond chronologic age. The traditional treatment for advanced disease has relied on platinum-based chemotherapy. These multi-agent regimens require consideration of baseline organ function as well as competing conditions that may heighten toxicity. The advent of a new class of cancer therapeutics, the immune checkpoint inhibitors, has changed the care of patients with advanced disease considerably. These immunotherapeutics have been approved for treating patients with disease progression on chemotherapy, or those who are ineligible (or unfit) to receive cisplatin-based therapy. This expansion of the population of patients eligible for treatment has great applicability to the unique considerations in an older patient population. In general, these new immunotherapies are well tolerated and effective in this group of patients.

Association between De Ritis ratio (aspartate aminotransferase/alanine aminotransferase) and oncological outcomes in bladder cancer patients after radical cystectomy

Background

New biological prognostic predictors have been studied; however, some factors have limited clinical application due to tissue-specific expression and high cost. There is the need for a promising predictive factor that is simple to detect and that is closely linked to oncological outcomes in patients with urothelial bladder cancer (BC) who have undergone radical cystectomy (RC). Therefore, we investigated the clinical prognostic value of the preoperative De Ritis ratio (aspartate aminotransferase/alanine aminotransferase) on oncological outcomes in patients with urothelial BC after RC.

Methods

We retrospectively evaluated clinicopathological data of 118 patients with non-metastatic urothelial BC after RC between 2008 and 2013 at a single center. The association between the De Ritis ratio and clinicopathological findings was assessed. The potential prognostic value of the De Ritis ratio was analyzed using the Kaplan-Meier method, and multivariate Cox analyses were performed to identify the independent predictors of metastasis-free survival, cancer-specific survival, and overall survival.

Results

According to the receiver operating curve of the De Ritis ratio for metastasis, we stratified the patients into 2 groups using a threshold of 1.3. A high De Ritis ratio was more likely to be associated with old age and the female sex. Kaplan-Meier estimates revealed that patients with a high De Ritis ratio had inferior metastasis-free survival, cancer-specific survival, and overall survival outcomes (P = 0.012, 0.024, and 0.022, respectively). Multivariate analysis revealed that a high De Ritis ratio was an independent prognostic factor for metastasis (hazard ratio [HR], 2.389; 95% confidence interval [CI], 1.161–4.914; P = 0.018), cancer-related death (HR, 2.755; 95% CI, 1.214–6.249; P = 0.015), and overall death (HR, 2.761; 95% CI, 1.257–6.067; P = 0.011).

Conclusions

An elevated De Ritis ratio was significantly associated with worse prognosis in patients who underwent RC for urothelial BC. This ratio might further improve the predictive accuracy for prognosis in BC.

Changes in Lean Muscle Mass Associated with Neoadjuvant Platinum-Based Chemotherapy in Patients with Muscle Invasive Bladder Cancer

Background:

Baseline sarcopenia or severe lean muscle deficiency is independently associated with increased mortality after cystectomy for muscle-invasive urothelial carcinoma of the bladder (MIUC). The impact of chemotherapy on muscle mass in MIUC patients remains undefined

Objectives:

To describe preoperative changes in body composition in MIUC patients receiving platinum-based neoadjuvant chemotherapy (NC).

Methods:

Patients with cT2-4 N0-1 M0 UC of the bladder who received NC were identified. Lumbar skeletal muscle index (SMI, cm²/m²), visceral adipose index (VAI, cm²/m²), and the subcutaneous and intramuscular adipose index (SAI, cm²/m²) were calculated using validated methodology (cross sectional area of skeletal muscle/height² at L3) from measurement of soft tissue areas on pre- (pre-NC) and post-NC (post-NC) computed tomography. Patients were classified as sarcopenic according to consensus definitions: Male: SMI <55 cm²/m², Female: SMI <38.5 cm²/m². Pre-NC and post-NC median body mass index (BMI kg/m²), SMI, and adipose indices were compared.

Results:

The study cohort consisted of 26 patients, with a median age 70 years, including 7 females (27%). Chemotherapy regimens included dose-dense methotrexate, vinblastine, doxorubicin and cisplatin (31%), gemcitabine/cisplatin (62%) and gemcitabine/carboplatin (3.8%) with a median of 3.5 (range 2–6) cycles. Median pre- and post-NC BMI were 27.1 kg/m² and 27.2 kg/m² (p = 0.36). Median pre- and post-NC SMI were 49.1 cm²/m² and 44.5 (p < 0.001) respectively. Median percent change in SMI was –6.4% (range –30% to 10%). Pre-NC, 18 (69%) patients were sarcopenic vs. 21 (81%, p = 0.002) post-NC. Median time between initiation of chemotherapy and cystectomy was 110 days.

Conclusions:

We observed a significant decrease in lean muscle mass among MIUC patients treated with platinum-based NC prior to cystectomy, with an associated increase in the prevalence of sarcopenia. Patients undergoing NC may benefit from pre-habilitative interventions to mitigate lean muscle loss prior to cystectomy.

Systematic Review of Comorbidity and Competing-risks Assessments for Bladder Cancer Patients

Context

Radical cystectomy continues to be associated with a significant risk of morbidity and all-cause mortality (ACM). Practice pattern data demonstrating underuse of surgery for patients with muscle-invasive and high-risk non-muscle invasive bladder cancer (BC) have been linked to the advanced age and higher comorbidity status of such patients, which suggests that rates of ACM as well as cancer-specific mortality should be incorporated into patient counseling and guideline recommendations.

Objective

To review the literature on risk assessment tools for preoperative comorbidity in BC that may aid in treatment decision-making.

Evidence acquisition

A systematic search was conducted using Ovid and Medline according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2017 reporting on comorbidity risk assessment (CRA) tools for BC. Prospective and retrospective studies were included.

Evidence synthesis

There are no published randomized control trials comparing CRA tools for BC. Patients undergoing radical cystectomy with combined high-risk comorbidity and performance scores may face up to a sevenfold greater risk of other-cause mortality compared to those with low scores. The Charlson Comorbidity Index is one of the most widely studied indices for 90-d perioperative mortality and overall and cancer-specific survival, with an area under the receiver operating characteristic curve of up to 0.810. Prospective studies of CRA tools for BC have consistently shown that patients with higher comorbidity have worse outcomes. While not specific for BC, comorbidity indices provide useful assessment of competing risks. Competing-risks assessment tools are lacking, with limited studies assessing the impact of these tools on treatment decision-making by patients and providers. We provide the impetus for incorporation of comorbidity risks into practice guidelines when discussing treatment options with patients.

Conclusions

CRA tools should be incorporated into preoperative treatment counseling and the assessment of postoperative outcomes. While retrospective evidence supports the use of CRA tools for BC, further comparative studies evaluating the effectiveness of these tools and identifying the patients most likely to benefit from a treatment according to competing-risks assessment are needed.

Patient summary

In this review we explored the clinical evidence for comorbidity risk assessment tools in bladder cancer. We found evidence to support incorporation of comorbidity risks into practice guidelines when discussing treatment options with patients.

Perioperative Preparation and Nutritional Considerations for Patients Undergoing Urinary Diversion

Patients undergoing urinary diversion are at high risk for complications in the perioperative period. The exact cause of these complications remains poorly defined but is likely multifactorial. Current efforts to optimize patients in the perioperative period, including prehabilitation, smoking cessation, recognition and treatment of comorbid conditions and malnutrition, immunonutrition supplementation, carbohydrate loading, and prevention of known complications and implementation of enhanced recovery after surgery pathways, seem beneficial in helping to improve outcomes in this at-risk population. Further studies (some of which are ongoing) are necessary to help optimize these strategies and identify which modifiable factors have the greatest impact.

Comparison of readmission and short-term mortality rates between different types of urinary diversion in patients undergoing radical cystectomy

PURPOSE

To analyze the impact of urinary diversion type following radical cystectomy (RC) on readmission and short-term mortality rates.

METHODS

Patients who underwent RC for bladder cancer in the National Cancer Data Base were grouped based on the type of urinary diversion performed: non-continent [ileal conduit (IC)] or two continent techniques [continent pouch (CP) and orthotopic neobladder (NB)]. We used propensity score matching and multivariable logistic regression models to compare 30-day readmission and 30- and 90-day mortality between the different types of urinary diversion.

RESULTS

Among 11,933 patients who underwent RC, we identified 10,197 (85.5%) IC, 1044 (8.7%) CP, and 692 (5.8%) NB. Patients who received IC were significantly older and had more comorbidities (p < 0.0001). Continent diversions were more likely to be performed at an academic center (p < 0.0001). Surgery performed at a non-academic center was an independent predictor of 30-day readmission (OR 1.19, p = 0.010) and 30-day mortality (OR 1.27, p = 0.043). Patients undergoing NB had an increased likelihood of being readmitted (OR 1.41, p = 0.010). There was no significant difference in short-term mortality between groups.

CONCLUSIONS

Patients undergoing NB had marginally increased rates of readmission compared to IC. Surgery performed at a non-academic center was associated with higher readmission and 30-day mortality. Similar short-term mortality rates were observed among the different types of urinary diversion.

Survival outcomes for patients with localised upper tract urothelial carcinoma managed with non-definitive treatment

OBJECTIVE

To investigate the outcomes of patients with upper tract urothelial carcinoma (UTUC) with non-definitive therapy, which currently remains unknown.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database to identify individuals with a localised, histologically confirmed kidney/renal pelvis and ureteric UC. Survival analysis using the Kaplan-Meier method was performed. A competing risk model evaluated the cumulative incidence and predictors of cancer-specific mortality (CSM).

RESULTS

We identified 633 (7.6%) individuals who did not receive surgery. These individuals were significantly older (median age 81 vs 71 years, P < 0.001) than surgically managed patients. The median overall survival (OS) was significantly shorter compared to the surgical cohort (1.9 vs 7.8 years, P < 0.001). The 3-year disease-specific survival (DSS) for patients without surgery was significantly lower compared to those with surgery, at 73.7% vs 92.4%, respectively (P < 0.001). The 3-year DSS for patients with high-grade tumours was worse when compared to patients with low-grade tumours, at 65.1% vs 82.9%, respectively (P < 0.001). The 3-year cumulative CSM was 26.3%. On multivariable analysis, older age (hazard ratio [HR] 1.05, P < 0.001) and high tumour grade (HR 1.88, P < 0.001) were predictors of worse outcomes.

CONCLUSIONS

In this population-based cohort, 7.6% of patients with UTUC were managed with a non-definitive approach. The median OS for the untreated cohort was significantly shorter compared to the surgical cohort (1.9 vs 7.8 years, respectively). These data may be helpful in counselling patients who are poor surgical candidates, as non-definitive therapy may provide reasonable oncological outcomes.

Treatment Patterns and Overall Survival Outcomes of Octogenarians with Muscle Invasive Cancer of the Bladder: An Analysis of the National Cancer Database

PURPOSE

Elderly patients with muscle invasive bladder cancer can pose a therapeutic dilemma, given multiple comorbidities which may preclude surgery. In this registry based analysis we investigated treatment patterns and survival outcomes in this group of patients.

MATERIALS AND METHODS

We queried the National Cancer Database for muscle invasive (cT2-T4aN0M0) bladder cancer in patients 80 years old or older who were diagnosed from 2004 to 2013. Patients included in study underwent transurethral resection of bladder tumor followed by radical cystectomy, radical cystectomy plus chemotherapy, radiation therapy alone, chemotherapy alone, chemoradiation or no treatment. We performed Kaplan-Meier, log rank and multivariate Cox proportional hazards regression and propensity score matching.

RESULTS

A total of 9,270 patients were identified with a median followup of 12.8 months. Median overall survival in patients treated with radical cystectomy alone was 23.2 months (95% CI 19.8-26.6), which was superior to that of chemotherapy alone or radiation therapy alone (p <0.0001). Those treated with chemoradiation had a median overall survival of 27.3 months (95% CI 25.0-29.7), which did not statistically differ from that of radical cystectomy alone (p = 0.39). Surgery plus chemotherapy showed the longest median overall survival of 34.5 months (95% CI 22.2-46.7, vs chemoradiation and radical cystectomy alone p <0.0001). On multivariate analysis and propensity score matching the best overall survival was seen in patients treated with surgery plus chemotherapy and there was no difference in overall survival between chemoradiation and radical cystectomy alone.

CONCLUSIONS

In elderly patients with muscle invasive bladder cancer chemoradiation is an alternative definitive treatment strategy with survival equal to that of surgery alone and superior to that of chemotherapy alone or radiation therapy alone. If a patient was able to receive neoadjuvant or adjuvant chemotherapy with surgery, additional survival was observed in this nonrandomized study.

Utilization and Outcomes of Radical Cystectomy for High-grade Non-muscle-invasive Bladder Cancer in Elderly Patients

BACKGROUND

Radical cystectomy (RC) represents a treatment option for patients with high-grade non-muscle-invasive bladder cancer (HG-NMIBC); however, perioperative morbidity is not insignificant, particularly in elderly patients. We sought to evaluate the associations of age with utilization and outcomes of RC for HG-NMIBC.

PATIENTS AND METHODS

Patients with HG-NMIBC diagnosed between 2004 and 2013 were identified in the National Cancer Database and stratified by age: ≤ 60, 61-70, 71-80, and > 80 years. Association between age and treatment with RC was assessed by multivariable logistic regression. Associations between age and overall survival were assessed using the Kaplan-Meier method. A multi-institutional analysis was performed to evaluate the associations of age with perioperative outcomes and survival among patients managed with RC for HG-NMIBC.

RESULTS

On multivariable analysis, age was associated with RC utilization, with the lowest usage in patients > 80 years (2.1%; P < .01). Upstaging at RC occurred in 40% of patients with HG-NMIBC, and no association of age with upstaging risk was noted. Significantly inferior overall survival was observed in the patients who were upstaged across age strata (all P < .01). In the multi-institutional cohort, age was not associated with risks of upstaging, receipt of transfusion, 30-/90-day complications, or recurrence-free or cancer-specific survival (all P > .05), whereas upstaging was associated with inferior recurrence-free and cancer-specific survival regardless of age.

CONCLUSION

RC for HG-NMIBC is used less frequently in older adults, despite similar risks of pathologic upstaging. As upstaging is associated with inferior survival regardless of age, these data suggest that elderly patients with HG-NMIBC may be at risk for undertreatment.

Laparoscopic Radical Cystectomy in the Elderly - Results of a Single Center LRC only Series

Objective:

To compare outcome of laparoscopic radical cystectomy (LRC) with ileal conduit in 22 elderly (≥75 years) versus 51 younger (<75 years) patients.

Materials and Methods:

Analysis of prospectively gathered data of a single institution LRC only series was performed. Selection bias for LRC versus non-surgical treatments was assessed with data retrieved from the Netherlands Cancer Registry.

Results:

Median age difference between LRC groups was 9.0 years. (77.0 versus 68.0 years). Both groups had similar surgical indications, body mass index and gender distribution. Charlson Comorbidity Index score was 3 versus 4 in ≥50% of younger and elderly patients. Median operative time (340 versus 341 min) and estimated blood loss (<500 versus >500mL) did not differ between groups. Median total hospital stay was 12.0 versus 14.0 days for younger and elderly patients. Grade I-II 90-d complication rate was higher for elderly patients (68 versus 43%, p=0.05). Grade III-V 90-d complication rate was equal for both groups (23 versus 29%, p=0.557). 90-d mortality rate was higher for elderly patients (14 versus 4%, p=0.157). Median follow-up was 40.0 months for younger and 57.0 months for elderly patients. Estimated overall and cancer-specific survival at 5years. was 46% versus 35% and 64% versus 64% for younger and elderly patients respectively.

Conclusions:

Our results suggest that LRC is feasible in elderly patients, where a non-surgical treatment is usually favoured.

Curative Treatment for Muscle Invasive Bladder Cancer in Elderly Patients: A Systematic Review

CONTEXT

The incidence of muscle invasive bladder cancer (MIBC) increases with age. With increased life expectancy the number of elderly MIBC patients is expected to increase. Existing guidelines on management of MIBC do not preclude curative treatments for elderly patients. However, it is necessary to assess the risks and benefits of a treatment to avoid overtreatment that results in decreased health-related quality of life without prolonging survival.

OBJECTIVE

To report on overall survival (OS), cancer specific survival (CSS), and morbidity after curative treatment in elderly patients, defined as age >70 yr, with nonmetastatic MIBC and to compare this with the outcome of younger MIBC patients.

EVIDENCE ACQUISITION

A systematic review was performed using Medline, PubMed, and Embase databases. Articles were included if they addressed one of the three research questions: Only articles including >100 patients and with a clear age-stratification were included.

EVIDENCE SYNTHESIS

Forty-two articles were retrieved for review. No article directly addressed the use of geriatric assessment. OS and CSS worsen significantly with age both after radical cystectomy and radiotherapy regimens. While POM significantly increases with age, morbidity seems comparable between younger and older patients.

CONCLUSIONS

Although a proportion of elderly patients with MIBC will benefit from curative treatment, we observed worse OS, CSS, and POM with age. The impact of age on late morbidity is less clear. Prospective studies evaluating geriatric assessments are critically needed to optimize MIBC management in the elderly.

PATIENT SUMMARY

We performed a systematic review to evaluate the outcome and complication rate in elderly patients with muscle invasive bladder cancer. We observed that overall survival and cancer specific survival significantly decrease and perioperative mortality significantly increases with age. The impact of age on late morbidity is less clear. There is a need for geriatric assessments to select those patients that will benefit from curative treatment.

Patterns of care in patients with muscle-invasive bladder cancer - a retrospective cohort study

A potential reason for poor survival among patients with muscle-invasive bladder cancer (MIBC) in Poland is initial disqualification from curative treatment due to advanced stage of the disease or low performance status. The aim of this study was to describe patterns of care in patients with newly diagnosed MIBC.

This is a multicentre retrospective cohort study involving 296 consecutive patients with primary histologically diagnosed MIBC. Therapeutic decisions and potentially underlying clinical factors were analysed.

Full clinical data was available for 285 patients. One hundred and sixty-four (57.5%) patients were qualified for radical cystectomy (RC), 32 (11.2%) patients for a second step of transurethral resection of the bladder tumour (TURBT) intentionally followed by systemic chemotherapy, four (1.4%) patients after complete TURBT were qualified for adjuvant intravesical chemotherapy only, while the remaining 85 (29.8%) patients were qualified for palliative treatment in the form of chemotherapy and/or radiotherapy and/or best supportive care. Patients disqualified from curative treatment were older (78 vs. 69 years, p < 0.02), had lower BMI values (24.5 vs. 25.7 kg/m², p < 0.02), lower haemoglobin concentration (11.6 vs. 12.9 mg/l, p < 0.02), declared lower rate of nicotine abuse (50.5% vs. 72.1%, p < 0.02), and had a shorter time interval between first symptom and diagnosis (30 vs. 60 days, p = 0.02).

As the majority of Polish patients with primary MIBC receive curative treatment, the stage of the disease alone seems not to be the leading cause of poor survival. However, appropriateness of qualification for RC and treatment quality needs to be assessed for final conclusion on the factors influencing outcomes of treatment in Poland.

Laparoscopic Versus Open Radical Cystectomy for Patients Older than 75 Years: a Single-Center Comparative Analysis

BACKGROUND

To explore the safety, efficacy, and oncological outcome of 3-port laparoscopic radical cystectomy (LRC) compared to open radical cystectomy (ORC) in patients older than 75 years.

MATERIALS AND METHODS

From June 2010 to July 2014, we analyzed 16 radical cystectomies in patients older than 75 years (LRC group=8; ORC group=8). Demographic parameters, operative variables, and perioperative outcome in the 2 groups were retrospectively collected, analyzed, and compared.

RESULTS

Patients in both groups had comparable preoperative characteristics. A significantly longer operating time (476 vs. 303 min, P=0.0002) and less estimated blood loss (627 vs. 2,106 mL, P=0.021) were observed in the LRC group compared to the ORC group. Infection and ileus were the most common early complications after surgery. Patients who underwent ORC suffered from more postoperative infection (22.2% vs. 0.0%, P=0.054) and ileus (25.0% vs. 12.5%, P=0.521) than the LRC group, but the difference was not significant.

CONCLUSIONS

Judging from this initial trial, 3-port LRC can be safely carried out in elderly patients. We suggest 3-port LRC as the primary intervention to treat muscle-invasive or high-risk nonmuscle-invasive bladder cancer in elderly patients with an otherwise relatively long life expectancy.

Treatment of bladder cancer in the elderly

As the population ages and life expectancy increases in the human population, more individuals will be diagnosed with bladder cancer (BC). The definition of who is elderly is likely to change in the future from the commonly used cut-off of ≥75 years of age. Physiological rather than chronological age is key. BC care in the elderly is likely to become a very common problem in daily practice. Concerns have been raised that senior BC patients are not given treatments that could cure their disease. Clinicians lack quantitative and reliable estimates of competing mortality risks when considering treatments for BC. Majority of patients diagnosed with BC are elderly, making treatment decisions complex with their increasing number of comorbidities. A multidisciplinary approach to these patients may be a way to incorporate discussion from various disciplines regarding treatment options available. Here we review various treatment options for elderly patients with muscle invasive BC and nonmuscle invasive BC. We include differences in treatments from robotic versus open radical cystectomy, various urinary diversion techniques, chemotherapy, radiation therapy and combination treatments. In clinical practice, treatment decisions for elderly patients should be done on a case-by-case basis, tailored to each patient with their specific histories and comorbidities considered. Some healthy elderly patients may be better candidates for extensive curative treatments than their younger counterparts. This implies that these important, life-altering decisions cannot be solely based on age as many other factors can affect patient survival outcomes.

Effects of Toceranib Phosphate on Systolic Blood Pressure and Proteinuria in Dogs

Background

Systemic hypertension and proteinuria are established adverse effects of tyrosine kinase inhibitor treatment in people.

Objective

The objective of this study was to investigate changes in systolic blood pressure and the incidence of proteinuria secondary to treatment with toceranib phosphate in dogs with cancer.

Animals

Twenty‐six control dogs and 30 dogs with cancer were evaluated for the first part of the study (baseline characteristics). For the second part (effect of toceranib phosphate treatment), 48 client‐owned dogs were evaluated, including 20 control dogs and 28 dogs with various types of neoplasia.

Methods

Prospective cohort study. Client‐owned healthy control dogs and dogs with cancer were enrolled. Blood pressure and urine protein:creatinine ratios were measured before treatment and 2 weeks after initiation of toceranib phosphate treatment.

Results

Systolic blood pressure was significantly (P = 0.0013) higher in previously normotensive treatment dogs after initiation of treatment with toceranib phosphate (152 mmHg ± 19) compared to baseline (136 mmHg ± 14). 37% of treated dogs developed SBP ≥ 160 mmHg. The prevalence of systemic hypertension (37%) and proteinuria (21%) at baseline in treatment dogs did not differ from that of age‐matched healthy controls (15% [P = 0.13] and 0% [P = 0.069], respectively).

Conclusions and Clinical Importance

Toceranib phosphate treatment might result in increased systolic blood pressures in dogs. Systemic hypertension should be considered a potential adverse effect of this drug in dogs. Systemic hypertension and proteinuria were detected at clinically relevant frequencies in the dogs with cancer before antineoplastic therapies suggesting that monitoring of these variables might be warranted in this population.

Management of muscle-invasive bladder cancer in the elderly

PURPOSE OF REVIEW

The number of cases of muscle-invasive bladder cancer is increasing along with the age of the population. Management of muscle-invasive bladder cancer in the elderly is complex, requiring a multidisciplinary team approach and a comprehensive assessment of each individual patient.

RECENT FINDINGS

A geriatric assessment should be used to inform treatment decisions in elderly patients with bladder cancer. There is increasing evidence to support aggressive therapy in appropriate elderly patients, including radical cystectomy and neoadjuvant chemotherapy. Adjuvant chemotherapy also has a role in patients with high-risk disease after cystectomy. A bladder preservation approach with trimodality therapy is a well tolerated and effective alternative to cystectomy in appropriately selected patients.

SUMMARY

Treatment decisions should not be based on chronologic age alone and advanced age should not preclude aggressive or curative therapy. The recent molecular characterization of bladder cancer and several recent immunotherapy trials provide hope of a more targeted approach to treatment of bladder, potentially improving both effectiveness and tolerability of treatment regimens in the elderly.

Complications from robot-assisted radical cystectomy: Where do we stand?

INTRODUCTION

Radical cystectomy with extended lymphadenectomy is the surgical treatment of choice for muscle-invasive bladder cancer. The technical and technological improvements and the positive results from robot-assisted kidney and prostate surgery have led to the progressive development of robot-assisted radical cystectomy (RARC). We provide a global structured overview and an update on the complications of RARC, recorded according to the Clavien-Dindo classification system.

ACQUISITION OF EVIDENCE

We conducted a search on PubMed of all publications on RARC to date (2014). Of the 259 publications found, we excluded review articles and cost analyses, publications with less than 30 cases, updates of previous studies and those whose main objective was the study of other issues related to RARC other than complications, leaving a total of 38 articles for the final analysis.

SUMMARY OF THE EVIDENCE

The most common complications associated with RARC are gastrointestinal, infectious and genitourinary system, mainly Clavien 1-2, followed by Clavien 3-4. RARC had lower overall complication rates than open radical cystectomy and laparoscopic radical cystectomy and had a lower incidence of severe complications, less intraoperative bleeding and better postoperative recovery.

CONCLUSIONS

Although further scientific evidence is needed, RARC is an increasingly widespread technique that appears to reduce complications as well as the need for transfusion, and it improves recovery times.

Impact of nerve stimulator-guided obturator nerve block on the short-term outcomes and complications of transurethral resection of bladder tumour: A prospective randomized controlled study

INTRODUCTION

In this prospective randomized controlled study, we investigated the efficacy of obturator nerve block (ONB) on adductor muscle spasm and related short-term outcomes and complications in patients who underwent transurethral resection of lateral wall-located bladder tumours (TURBT).

METHODS

Between July 2014 and February 2015, 70 patients scheduled to undergo TUR of lateral bladder wall tumours were enrolled in the study. All patients were preoperatively evaluated by cystoscopy and imaging tools and selected according to localized tumours on the lateral bladder wall. Patients were randomly allocated to Group SA (35 patients who underwent only spinal anesthesia) and Group ONB (35 patients who underwent spinal anesthesia combined with ONB by the nerve stimulator). An independent observer, blinded to the approach, evaluated the obturator signs, including adductor muscle contraction, bladder perforation, and completeness of the resection during the TURBT procedure.

RESULTS

The differences between groups regarding mean operation time, tumour size, and number were not statistically significant (p > 0.05). Adductor muscle contraction was detected in 40% of patients in Group SA and 11.4% in Group ONB. This difference was statistically significant (p = 0.021). Complete bladder perforation was detected in 2 patients in Group SA, whereas no perforation was observed in Group ONB. There was no case of severe bleeding in both groups.

CONCLUSIONS

We found that ONB performed after spinal anesthesia was effective in preventing intraoperative complications due to adductor muscle spasm while performing TURBT. Our study limitations include its small sample size, since we only enrolled patients with primary lateral wall-localized bladder tumour. Also, we excluded patients who underwent bipolar TURBT.

There is a place for radical cystectomy and urinary diversion, including orthotopic bladder substitution, in patients aged 75 and older: Results of a retrospective observational analysis from a high-volume center

INTRODUCTION

The incidence of cancer increases with age and owing to the changing demographics we are increasingly confronted with treating bladder cancer in old patients. We report our results in patients>75 years of age who underwent open radical cystectomy (RC) and urinary diversion.

MATERIAL AND METHODS

From January 2000 to March 2013, a consecutive series of 224 old patients with complete follow-up who underwent RC and urinary diversion (ileal orthotopic bladder substitute [OBS], ileal conduit [IC], and ureterocutaneostomy [UCST]) were included in this retrospective single-center study. End points were the 90-day complication rates (Clavien-Dindo classification), 90-day mortality rates, overall and cancer-specific survival rates, and continence rates (OBS).

RESULTS

Median age was 79.2 years (range: 75.1-91.6); 35 of the 224 patients (17%) received an OBS, 178 of the 224 patients (78%) an IC, and 11 of the 224 patients (5%) an UCST. The 90-day complication rate was 54.3% in the OBS (major: Clavien grade 3-5: 22.9%, minor: Clavien Grade 1-2: 31.4%), 56.7% in the IC (major: 27%, minor: 29.8%), and 63.6% in the UCST group (major: 36.4%, minor: 27.3%); P = 0.001. The 90-day mortality was 0% in the OBS group, 13% in the IC group, and 10% in the UCST group (P = 0.077). The Glasgow prognostic score was an independent predictor of all survival parameters assessed, including 90-day mortality. Median follow-up was 22 months. Overall and cancer-specific survivals were 90 and 98, 47 and 91, and 11 and 12 months for OBS, IC, and UCST, respectively. In OBS patients, daytime continence was considered as dry in 66% and humid in 20% of patients. Nighttime continence was dry in 46% and humid 26% of patients.

CONCLUSION

With careful patient selection, oncological and functional outcome after RC can be good in old patients. Old age as the sole criterion should not preclude the indication for RC or the option of OBS. In old patients undergoing OBS, satisfactory continence results can be achieved.