Morbidity, mortality, and quality assessment following open radical cystectomy in elderly patients with bladder cancer

Radical cystectomy mortality in older patients: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of post-radical cystectomy (RC) mortality and complications in older people to aid decision-making pertinent to RC, as bladder cancer is typically a disease of older people, yet older people are less likely than their younger peers to undergo RC, predominantly due to concerns about morbidity and mortality of surgery.

MATERIALS AND METHODS

A systematic search of MEDLINE, Scopus and Ovid Emcare was performed in May 2023 for all studies in the past 20 years that reported mortality and/or complications in the 90-days following RC. All studies reporting mortality or complication outcomes in patient groups aged >75 years were included. Exclusion criteria included partial, or organ-sparing cystectomy, non-English language articles, and <20 patients aged >75 years.

RESULTS

A total of 76 studies were included, with data from 58 504 older patients across five continents and 19 countries. Post-RC 90-day mortality was 11% in studies reporting outcomes for patients aged ≥80 years, and 7% in studies of patients aged ≥75 years. The 90-day mortality was higher in patients aged ≥80 years compared to patients aged <80 years (odds ratio [OR] 3.42, 95% confidence interval [CI] 1.62-7.22). Older people were more likely to experience a minor (Clavien-Dindo Grade I-II) postoperative complication than younger patients (OR 1.17, 95% CI 1.01-1.36), whereas there was no difference for major complications (Clavien-Dindo Garde III-IV; OR 1.00, 95% CI 0.63-1.60). A higher co-morbid status was more strongly correlated with 90-day mortality in older patients than in younger patients.

CONCLUSIONS

Older patients face higher postoperative mortality following RC than younger patients. Postoperative outcomes should be weighed against the high risk of cancer-specific death if no curative treatment is offered. Older people must be monitored closely postoperatively to try and prevent death as a result of escalation from minor and major complications.

Bladder preservation in older adults with muscle-invasive bladder cancer: A retrospective study with concurrent chemotherapy and twice-daily hypofractionated radiotherapy schedule

BACKGROUND

Bladder cancer occurs mainly in older adults and surgery is not always possible when there are geriatric conditions and comorbidities. Trimodal treatment (TMT) combining trans-urethral resection of bladder tumour (TURBT) followed by concurrent chemoradiation (CRT) would be a curative alternative in such patients.

METHODS

All consecutive patients 75 years of age and older with non-metastatic muscle-invasive bladder cancer (MIBC) treated with TMT by Georges Pompidou European Hospital team were retrospectively analysed. Induction CRT combined hypofractionated twice-daily radiotherapy targeting bladder and pelvis to a total dose of 24 Gy (Gy) with concurrent platinum salt and 5-fluorouracil. Consolidation CRT to a total dose of 44 Gy was proposed to patients with biopsy-proven complete response after induction phase and those with persistent tumour underwent salvage cystectomy. We assessed using Kaplan-Meier method overall survival (OS), cancer specific survival (CSS), invasive recurrence-free survival (IRFS), metastasis-free survival (MFS), survival with bladder preserved (SBP), and toxicities. With a Cox model for OS and the Fine Gray method of competing risk for secondary endpoints, we analysed in univariate (u) and multivariate (m) analysis the impact of tumour characteristics and patient profiles: gender, age, age-adjusted Charlson comorbidity index, polypharmacy, and malnutrition.

RESULTS

From 1988 to 2017, 85 patients were included. After induction, complete response rate was 83.5%. With a median follow-up of 63 months, 5 year-OS, CSS, IRFS, MFS and SBP were 61.0%, 77.6%, 71%, 82.9%, and 70.2% respectively. A persistent tumour after induction impacted SBP (SHRm 3.61; p = 0.004), CSS (SHRm 3.27; p = 0.023), and MFS (SHRm 3.68; p = 0.018). Late grade 3 urinary and gastrointestinal toxicities were 3.5% and 1.2%.

CONCLUSION

We report here the largest series of bladder preservation over 75 years in a curative intent. Outcomes and tolerance in selected older adults compared favourably with surgical series and with CRT studies using classical fractionation.

The View Outside of the Box: Reporting Outcomes Following Radical Cystectomy Using Pentafecta From a Multicenter Retrospective Analysis

We aimed at characterization of the patients undergoing radical cystectomy (RC) using the prognostic model (a modified pentafecta). In the multicenter retrospective study, we enrolled 304 patients with bladder cancer (pTis-4N0-2M0) who underwent RC between 2015 and 2020 in experienced centers. The definition of the pentafecta was as follows: no Clavien–Dindo grade III–V complications at 90 days and no long-term complications related to urinary diversion <12 months, negative surgical margins, ≥10 lymph nodes (LNs) resected, and no recurrence ≤12 months. RC-pentafecta achievement rate was 22% (n = 67), varying from 47% to 88% attainment rate for different pentafecta components, and was the lowest for sufficient LN yield. Both 12-month recurrence-free survival (RFS) and cancer-specific mortality were compromised in pentafecta failers compared with achievers (57.8% vs. 100% and 33.8% vs. 1.5%, respectively). The following were identified as crucial predictors of RC pentafecta achievement: modality of the surgery, type of urinary diversion, histological type of bladder cancer, advanced staging, and elevated preoperative serum creatinine. In conclusion, we found that the pentafecta achievement rate was low even in high-volume centers in patients undergoing cystectomy. The complexity of the procedure directly influenced the attainment rate, which in turn led to an increase in cancer-specific mortality rate among the pentafecta failers.