RECONSTRUCTIVE UROLOGY

Surgical management of infiltrating bladder cancer in elderly patients
Peyromaure M, Guerin F, Debre B, Zerbib M
Department of Urology, Cochin Hospital, Paris, France
Eur Urol. 2004; 45: 147-54

• Objectives: To review the surgical therapeutic options in elderly patients with infiltrating bladder cancer.
• Methods: A review of the literature relevant to cystectomy and transurethral resection for infiltrating bladder cancer in elderly patients was conducted using Medline Services.
• Results: Thanks to progress in anaesthesia, intensive care and surgery, cystectomy now forms part of the classical treatments for bladder cancer in elderly patients, with acceptable mortality and morbidity rates. The recent series of cystectomies performed in patients over 75 years old report a mortality rate associated with the procedure of less than 4.5%. The global mortality rate in the same population ranges from 10 to 50%. These rates are now similar to those reported in the general population. The mean survival after cystectomy in patients over 75 years old is more than 2 years. Global survival at 5 years is between 37 and 68%. It is acknowledged by most authors that resection alone is associated with higher relapse and progression rates than cystectomy.
• Conclusions: Cystectomy appears to be reasonable in elderly people who have a life expectancy of more than 2 years, provided that a rigorous pre-operative assessment and anaesthetic management are performed. Transurethral resection alone should be proposed only to patients with poor health status and/or very advanced age.
  
  
• Editorial Comment
  The subject of this paper-whether radical cystectomy for muscle-invasive bladder cancer is justified in older patients-has been addressed by several authors in recent years. When dealing with this question, first of all the term “elderly” or “old” has to be defined. In this paper, elderly patients were those beyond 75 years, other authors included only patients older than 80 years. However, even if a clear definition is made we still have to question if every 75 or 80 year old can be compared based on his year of birth. In the clinical setting, the biological age is of much greater importance. Consciously or unconsciously, we tend to select patients who we assume are fit for such a procedure. If we make the wrong assumption and some surgeons are probably better than others, patients will have a larger chance of complications. This makes it difficult to compare different studies as long as we do not have better ways to define the biological age and not the actual age.
  Another important aspect in this patient group is not only whether the patient survives the surgical procedure but also whether he lives long enough to benefit from an oncological aspect, that is to say “would he have lived long enough to die really from bladder cancer”. And how does an increase of live expectancy of a few years weigh against an incontinent urinary diversion. We should consider cystectomy for localized bladder cancer in patients of advanced age, but the oncological benefit and quality of life in these patients must be put into strong consideration.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany