Bladder Preservation in Octogenarians With Invasive Bladder Cancer

Ileal conduit versus single stoma uretero-cutanoustomy after radical cystectomy in patients ≥ 75 years; which technique is better? a prospective randomized comparative study

PURPOSE

To compare the clinical results and patients' health-related quality of life (HR-QoL) of ileal conduit (IC) versus single stoma uretero-cutanoustomy (SSUC) after radical cystectomy in two groups of randomly selected patients ≥ 75 years.

METHODS

From January 2013 to March 2018, 100 patients ≥ 75 years with muscle invasive BCa underwent RCX and cutaneous diversion. Patients were divided in two groups; group I underwent IC (50 patients) and group II underwent SSUC (50 patients). Postoperative evaluation included clinical, laboratory, radiographic and HR-QoL. The latter was performed using the Functional Assessment of Cancer Therapy-Bladder Cancer (FACT-BL) after 12 months postoperatively.

RESULTS

Patients' characteristics were comparable between both groups. No intraoperative complications occurred. Early postoperative complications occurred in 27 patients [16 (35.5%) in group I and 11 (23.9%) in group II (p = 0.02)]. Delayed postoperative complications occurred in 26 patients [6 (13.3%) in group I and 20 (43.4%) in group II, (P = 0.002)]. No significant differences between both groups regarding the physical, social/family, emotional, functional and additional concerns scales of FACT-BL questionnaire were reported.

CONCLUSION

SSUC is a good alternative to IC in elderly frail patients  ≥ 75 years and those with multiple comorbidities who require rapid surgery in terms of perioperative complications and HR-QoL. However, the stomal complications and the possibility of a frequent stent exchange are considered its drawbacks.

Elderly patients undergoing cystectomy, comparing preoperative American Society of Anesthesiology and Eastern Cooperative Oncology Group scores and operative approaches

Objective:

To evaluate preoperative scoring systems and operative management and their relation to complications in patients older than 75 years undergoing cystectomy at two academic institutions.

Methods:

In total, 212 patients aged 75–95 years with muscle invasive bladder cancer underwent cystectomy at the University of Utah and Central Hospital of Bolzano, Italy. The rates of Grade 3 Clavien-Dindo complications and above in radical cystectomy patients (n = 199) were compared using Eastern Cooperative Oncology Group Scores and American Society of Anesthesiologists Physical Status Classification. The rates of Grade 3 Clavien-Dindo complications and above were also compared by urinary diversion type. Logistic regression was used to control for source institution.

Results:

In total, 199 cases were included in the primary analysis. Neither of the preoperative scoring systems were predictive for identification of radical cystectomy patients with ⩾Grade 3 Clavien-Dindo complications. In secondary analysis (n = 212, including partial cystectomy), none of the urinary diversion types associated with radical cystectomy had a significantly different rate of complications. However, partial cystectomy (n = 13) had a significantly lower rate of complications.

Conclusion:

Complication rates among elderly patients undergoing cystectomy for muscle invasive bladder cancer were very high. For patients who are approved for surgery after the history and physical exam, none of our objective metrics adequately predicted operative risk. A unique diversion procedure described by the Bolzano group, uretero-ureterocutaneostomy, had equivalent complication rates to the more common diversion procedures. It also appears based on outcomes in this cohort that partial cystectomy is a particularly favorable option within the elderly population in terms of perioperative morbidity.

Bladder cancer in nonagenarians: a multicentre study of 123 patients

OBJECTIVE

To investigate the oncological outcome of nonagenarians with bladder cancer, as a substantial rise in bladder cancer in the old-old age group in the upcoming decades is expected, due to demographic changes and the peak incidence around the age of 85 years. The paucity of data of nonagenarians prompted us to investigate the outcomes of such patients.

PATIENTS AND METHODS

A retrospective, multicentre study was designed to assess patient demographics, tumour patterns, treatment strategies and outcome in patients aged ≥90 years treated at participating centres. Patients entered either as de novo or as recurrent cancer. The study period ranged from 01.01.2006 to 31.12.2016.

RESULTS

A total of 123 patients with a mean (range) age of 91 (90-99) years were recruited. The American Society of Anesthesiologists Physical Status Classification (ASA-score) distribution was as follows: II, 38%; III, 50%; IV, 12%; and the male to female ratio 2.4:1. The median (range) follow-up was 8 (1-132) months. In all, 60% of patients had a de novo cancer diagnosis. Histological findings revealed: pTa 39% (n = 48), pT1 28.5% (n = 35), and ≥pT2 33% (n = 40). Overall, 67.5% patients had no recurrence, 25.2% one and 7.5% two or more. pTa tumours (n = 48) recurred in 20 patients (42%), pT1 tumours (n = 35) in 12 (34%), and ≥pT2 tumours (n = 40) in six (15%). The median overall survival (OS) was 30.0 months for patients with pTa tumours, 14.0 months for pT1 tumours, and 6.0 months for ≥pT2 tumours. The overall mortality rate of patients with pTa tumours was 40%, with pT1 tumours at 60%, and ≥pT2 tumours 75%. The ASA-score also had a strong influence on median OS after stratification by ASA-score (II, 30 months; III, 12 months; IV, 4 months).

CONCLUSIONS

In nonagenarians with bladder tumours, pTa/pT1/≥pT2 stages are almost evenly distributed and two-thirds of patients had no recurrence after transurethral resection of the bladder. The mean OS was 1.3 years, and 6 months for ≥pT2 tumours. Further case-series of patients in this specific age-group are required to identify the best management of this increasing proportion of patients with bladder tumours.

Evaluation and Management of the Geriatric Urologic Oncology Patient

The geriatric population presents a unique set of challenges in urologic oncology. In addition to the known natural history of disease, providers must also consider patient factors such as functional and nutritional status, comorbidities and social support when determining the treatment plan. The development of frailty measures and biomarkers to estimate surgical risk shows promise, with several assessment tools predictive of surgical complications. Decreased dependence on chronologic age is important when assessing surgical fitness, as age cutoffs prevent appropriate treatment of many elderly patients who would benefit from surgery. Within bladder, kidney and prostate cancers, continued refinement of surgical techniques offers a broader array of options for the geriatric patient than previously available.

Radical cystectomy in patients over 80 years old in Quebec: A population-based study of outcomes

OBJECTIVES

To document radical cystectomy (RC) outcomes in patients over 80 years old across Quebec during the years 2000-2009 and to examine potentially related factors.

METHODS

Within Quebec health insurance medical services database, we identified patients over 80 years who underwent RC. The outcomes analyzed were post-operative complications, mortality rates at 30, 60 and 90 days and overall survival.

RESULTS

A total of 275 patients over 80 years old had RC performed in 38 hospitals across Quebec. Among them, 33% had major post-operative complications with 16% having more than one complication. Mortality rates at 30, 60 and 90 days were 5.8%, 9.8% and 13% respectively. 44.3% of RCs were performed in seven academic hospitals with mortality rates of 2.5%, 6.5% and 9% respectively. Community hospitals had mortality of 8.5%, 12.4% and 16.3% respectively (P < 0.001). The cohort 5-year overall survival rate was 27%. The presence of post-operative complications and the number of complications negatively affected overall survival (P < 0.001) CONCLUSION: Patients over 80 years of age have high post-RC mortality rates, especially at 90 days. In addition, it appears that they have lower post-operative mortality if their RCs were performed in academic centers. Mortality rates and complications can be used when obtaining informed consent.

Impact of the Use of Bowel for Urinary Diversion on Perioperative Complications and 90-Day Mortality in Patients Aged 75 Years or Older

Objective: A potential strategy to decrease the high complication rate of radical cystectomy (RC) in the elderly is to avoid the use of bowel for urinary diversion. The aim of this study was to address this issue in a multicentre study of patients aged ≥75 years. Patients and Methods: We performed a retrospective, multicentre study of a consecutive series of patients aged ≥75 years who underwent RC for muscle-invasive bladder cancer between 2006 and 2010. Medical, surgical and wound complications were graded according to the modified Clavien-Dindo classification. Results: A total of 256 patients (68% men, mean age 79.6 years) were analysed. 204 (80%) patients received a urinary diversion with use of bowel and 52 (20%) a ureterocutaneostomy (UC). Patients with UC were older (82.0 vs. 78.9 years, p < 0.001) and had a higher ASA score (2.6 vs. 2.3, p = 0.007), while the mean Charlson score was lower (4.2 vs. 5.6, p < 0.001). Patients with UC had a shorter operating time (279 vs. 311 min, p = 0.002) and a shorter period in the intensive care unit (0.9 vs. 2.2 days). The overall rate of severe complications graded as Clavien III-V was significantly lower in the UC group (11.5%) as compared to patients receiving bowel for urinary diversion (25.0%) (p = 0.003). Severe (Clavien grade III-V) medical (3.9 vs. 10.3%) and surgical (2.1 vs. 14.1%) complications were all less frequent in the UC group. Inpatient, 30- and 90-day mortality was 5.8, 7.7 and 17.3% in the UC group as compared to 3.9, 5.9 and 6.9% in the bowel cohort, respectively. Conclusion: UC following RC is associated with a lower complication rate in geriatric patients. The constantly increasing cohort of geriatric, multimorbid patients requiring cystectomy might justify reconsideration of this form of diversion.

Comparison of Complications from Radical Cystectomy between Old-Old versus Oldest-Old Patients

Introduction: The purpose of this study was to evaluate and compare complications after radical cystectomy in patients aged ≥75 years. Materials and Methods: 251 patients aged 75-95 years (median 79) underwent radical cystectomy between 2000 and 2012 at four institutions. The patients were divided into two groups: ≥75-84 years of age (group 1) versus ≥85 years of age (group 2). Comorbidities, body mass index, and complications were obtained retrospectively, except at the Central Hospital of Bolzano and Weill Cornell Medical Center, which collected data prospectively. Cancer-specific survival, overall mortality, hospital stay, clinical outcome and complications were assessed. Complications were categorized using the Clavien-Dindo classification reporting system. The mean follow-up was 21 months. Results: The median hospital stay was 17 (2-91) days. Perioperative Clavien-Dindo grade ≥III complications were seen in 24.1% (48/199) of group 1 patients and 19.2% (10/52) of group 2 patients (p = 0.045). 30- and 90-day mortality was 4.5 and 13.5% in group 1 and 6.5 and 32.3% in group 2, respectively. Only the 90-day mortality rate was statistically significant (p < 0.05) between the two groups. The 3-year overall survival was 40% in group 1 and 34% in group 2. The 3-year cancer-specific survival was 52% in group 1 and 50% in group 2. Conclusions: We evaluated a large series of elderly (≥75 years) patients undergoing radical cystectomy at four institutions. Comparing patients aged ≥75-84 and ≥85 years revealed no significant difference in complications, 30-day mortality, overall and cancer-specific survival rates. Only 90-day mortality rates were significantly higher in the ≥85-year-old patients.

[Cystectomy in elderly patients: analysis of complications using the Clavien-Dindo classification]

Radical cystectomy (RC) represents the gold standard in the treatment of muscle invasive urothelial cancer of the bladder. Due to improvements in operation techniques and perioperative care it has become a good and safe procedure even in elderly patients. In recent years the Clavien-Dindo classification has been frequently used for complication assessment in urological research. The Charlson comorbidity index without age correction can be used in treatment planning for RC to identify patients at risk.

Radical cystectomy over the age of 75 is safe and increases survival

Background

Radical cystectomy (RC) is probably underused in elderly patients due to a potential increased postoperative complication risk, as reflected by their considerable comorbidities. Our objective was to estimate the overall complication rate and investigate a potential benefit to patients over the age of 75 subjected to RC in terms of disease-free survival.

Methods

A total of 81 patients, 61 men and 20 women, from two urological departments, with a mean age of 79.2 ± 3.7 years, participated in the study. The mean follow-up period was 2.6 ± 1.6 years. All patients underwent RC with pelvic lymphadenectomy. An ileal conduit, an orthotopic ileal neobladder and cutaneous ureterostomies were formed in 48.1%, 6.2% and 45.7% of the patients, respectively. The perioperative and 90-day postoperative complications were recorded and classified according to the modified Clavien classification system. Survival plots were created based on the oncological outcome and several study parameters.

Results

The perioperative morbidity rate was 43.2%; the 90-day morbidity rate was 37%, while the 30-day, 90-day and overall mortality rates were 3.7%, 3.7% and 21%, respectively. Overall mortality rates were recorded at the final year of data gathering (2009). Increased age, increased body mass index (BMI), longer hospitalization and age-adjusted Charlson comorbidity index (ACCI) more than six, were associated with greater hazard for 90-day morbidity. The cumulative mortality / metastasis-free rates for one, two, three and five years were 88.7%, 77.5%, 70.4%, and 62.3%, respectively. Tumour stage and positive nodes were prognostic predictors for oncological outcome.

Conclusions

RC in patients over 75 is justified and feasible, due to acceptable complication rates and high 5-year cancer-specific survival, which support an aggressive approach. Prospective studies are needed for the verification of the above results.

Does radical cystectomy improve overall survival in octogenarians with muscle-invasive bladder cancer?

PURPOSE

We compared the efficacy of radical cystectomy (RC) and non-RC treatment [transurethral resection of bladder tumor (TURB) only, partial cystectomy, or TURB followed by radiotherapy] in octogenarians with muscle-invasive bladder cancer (MIBC).

MATERIALS AND METHODS

A total of 177 patients aged 80 years or more underwent TURB at our institute, and 41 patients had MIBC according to the histologic examination. Fourteen patients with lymph node or distant metastasis were excluded, and 27 patients were ultimately included. Patients were stratified by treatment modality (RC vs. non-RC), Charlson Comorbidity Index (low CCI vs. high CCI), and clinical tumor stage (organ-confined disease vs. extravesical disease). The effects of several variables on cancer-specific and overall survival were assessed.

RESULTS

Of the 27 patients, 11 (41%) underwent RC and 16 (59%) underwent non-RC treatment. Patients in the RC group were younger and more likely to have low CCI scores. There were no significant differences in overall or cancer-specific survival in the RC and non-RC groups. Patients with clinically organ-confined disease had better survival outcomes than did those with extravesical disease. Stratification of patients by CCI indicated that overall survival was better in patients with low CCI scores (p=0.013), although cancer-specific survival was similar in the two CCI groups. Univariate and multivariate analysis indicated that clinical tumor stage and CCI were independently associated with overall survival.

CONCLUSIONS

RC in octogenarians with MIBC does not improve overall survival compared with other treatment modalities. However, clinically organ-confined disease and low CCI score were associated with better overall survival.

Management of bladder cancer in the elderly: clinical decision-making and guideline recommendations

Evaluation of: Bolenz C, Ho R, Nuss GR et al.: Management of elderly patients with urothelial carcinoma of the bladder: guideline concordance and predictors of overall survival. BJU Int. (2010) (Epub ahead of print). Treatment recommendations for all stages of bladder cancer have been proposed in the form of clinical guidelines from the European Association of Urology and the American Urological Association. However, the therapeutic considerations, especially when dealing with elderly patients with limited functional status and associated comorbidities, may be much more complex. This retrospective study reviewed the records of 206 patients aged over 75 years with bladder cancer and compared their subsequent treatment with established European Association of Urology and American Urological Association guidelines to see if their actual treatment was concordant or discordant with the published recommendations. Overall guideline concordance was relatively high (88.8%) at this tertiary referral institution. While treatment of muscle-invasive bladder cancer in the elderly can be performed in accordance with accepted guidelines, the margin of error is greatly reduced and proper patient selection and attention to detail is critical to ensure a favorable outcome. Further research is needed to more objectively distinguish patients who may benefit from aggressive cancer therapy from those with serious competing risks who would probably die from other causes.