The treatment of bladder cancer in elderly patients is still a controversial issue for urologists. Although many reports recommended RC as a therapeutic option for octogenarians[12,7,13]. More potential anesthesia risks, more comorbid conditions and shortened life expectancy in elderly patients often drive physicians and patients away from cystectomy[14–16].
With the development of minimally invasive surgery, especially robot-assisted surgery, the perioperative outcomes, including estimated blood loss(EBL), blood transfusion rates and rehabilitation, have been improved without sacrificing the oncologic results[6,17]. In our cohort, the whole cohort also had a lower EBL than that in the previous open RC cohort[17]. Those suggest that RARC may bring better benefits to the elderly in the respect of intraoperative damage control and enhance the safety of operation relatively. Furthermore, compared with younger group, Groote et al. found that elderly group had similar EBL and significantly shorter operative time[12]. Our study found similar results, but we also suggested that the elderly group had higher blood transfusion rate. It may attribute to the lower preoperative hemoglobin in the elderly group than in the younger group (119 vs 126g/L, p = 0.015). And the concerns about elderly patient frailty and relatively poor compensatory ability after blood loss may lead anesthesiologists to relax blood transfusion indications during operation[18]. Meanwhile, that surgeons tended to operate faster to reduce anesthetic risks in elderly patients, so ileal conduit and lymphadenectomy was less performed in the elderly group than in the younger group.
RC and urinary diversion present challenges of complications to all the patients, especially to the elderly. A comparative study of RC with different approaches for patients over 75 years suggested that there were no significant differences in surgical morbidity or 90-day readmission rates between the RARC and open RC groups, but RARC was correlated with a shorter hospital stay[19]. In our cohort, the incidence of postoperative complications in elderly patients was lower than that in the previous open RC cohort of elderly patients[20]. Those may indicate that RARC has relative advantages over open RC in terms of postoperative rehabilitation of elderly patients. Moreover, in terms of distribution of complications in different grades or 90-day mortality, Groote et al. showed that there was no significant difference between the elderly and young group, but they did not analyze the influencing factors of complications[12]. Our research has come to a similar conclusion, and further analysis showed that ASA score and CCI, rather than age, could predict major and any grade complications respectively. Previous RARC cohort also showed that high ASA score was independent predictor of major complications[21]. Therefore, the incidence of complications after RARC is mainly related to the basic physical condition of the patients, but not to the age.
With regard to survival outcomes, Groote et al. has shown that elderly patients had a similar 3-year RFS but worse CSS compared with young patients, and pathological stage was still the main predictors of survival outcomes[12]. In our study, the octogenarians also had a similar 3-year RFS (Figure.1), and tumor stage and positive lymph node, rather than age, were significant predictors of oncologic outcomes. However, OS and CSS were significantly higher in elderly. Relatively higher tumor stage, less use of PLND, and physical condition may result in poor OS and CSS for the elderly. Firstly, we have already pointed out that high tumor stage was associated with survival outcomes. Secondly, Chamie et al. suggested that the survival benefit of RC in the elderly is mainly acquired by the use of PLND[22]. Although the PLND ratio of the elderly patients in our study (75%) was higher than that of the previous elderly cohorts (32%)[12,23], it was still lower than that of the younger patients (89%). This may be due to multidisciplinary discussions among urologists and anesthesiologists, as well as concerns about postoperative complications. Lastly, the impacts of ASA score and CCI, which can reflect the physical condition of the elderly, on long-term survival outcome are still controversial. Previous study has suggested that CCI is an independent predictor of OS[24], but other study has shown that neither CCI nor ASA could was predictor of 5-year competing (non-bladder cancer) mortality[25]. In our cohort, Cox multivariable regression analysis show that ASA score and CCI can independently predict OS and RFS, respectively. The differences in the accuracy of cancer information record, follow-up time and sample size may be the explanation for these different findings[24]. To summarize, age should not be the only consideration for the elderly patients with bladder cancer. Preoperative comprehensive assessment is very important for the operation of elderly patients.
This study possessed several limitations. Firstly, our study was a retrospective study in which the survival data were acquired through follow-up, thus we may not be able to obtain information such as the exact time of recurrence and death of the patient. Moreover, including more elderly patients and prolonging the follow-up time will have more persuasion. Finally, selection bias for RARC may also have influenced our results, which make it possible for only elderly patients with relatively good health condition to underwent RARC.