| RE:
RESULTS FROM THREE MUNICIPAL HOSPITALS REGARDING RADICAL CYSTECTOMY ON
ELDERLY PATIENTS
(
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MATTHIAS MAY, STEPHANIE
FUHRER, KAY-P. BRAUN, SABINE BROOKMAN-AMISSAH, WILLI RICHTER, BERND HOSCHKE,
HORST VOGLER, MICHAEL SIEGSMUND
Department
of Urology (MM, BH, SF, KPB, SBA), Carl-Thiem Hospital, Cottbus, Department
of Urology (MS,WR), Vivantes-Clinic Am Urban, Berlin and Department of
Urology (HV), Vivantes-Clinic Friedrichshain, Berlin, Germany
Int
Braz J Urol, 33: 764-776, 2007
To the Editor:
The
evaluation of radical cystectomy outcomes in the elderly population is
an important issue. The authors present their data from three community
hospitals and we need to congratulate them for the needed considerable
effort. The median age median of this cohort was 77.6 years, with only
22 patients being older than 77 years. Nonetheless, this study supports
the fact that older patients can safely undergo radical cystectomy at
municipal centers.
Surgical volume of radical cystectomy is
an important predictor of risk of complications and overall survival.
The focus of the present study is municipal non-university related hospitals,
where the overall mean volume was about 12.5 cases per year per hospital.
This would be appropriately called an intermediate or even a high volume
institution (1), not a low volume institution where the risk of complications
is consistently proven to be higher.
An intriguing finding of the present series
is that the overall survival equals progression free survival. Bladder
cancer patients, especially older patients, would be expected to have
competing risks for mortality other than bladder cancer, especially when
considering this cohort, which had a mean ASA class of 3. The authors
state that virtually all the patients died of bladder cancer. Although
the follow-up is perhaps too short to fully evaluate this point, we would
still expect a small difference between overall and progression free survival
at 5 years. For organ-confined, extra-organ and node positive disease,
the difference is about 7%, 15% and 27% (2). We want to stress the point
that risk of complication must always be balanced against invasiveness
and quality of the oncologic procedure.
Retrospective comparison of outcomes between
different institutions is beset with major methodological difficulties.
There are often major differences in patient population and selection
biases, different definition of outcomes, different approaches in disease
management and surgical techniques, to name only a few potential limitations.
One must also note that the retrospective comparison of patient groups
within institutions is threatened by the same biases. It is also important
to note that other patient specific characteristics not commonly recorded
such as cognitive status and functional status can also have a direct
impact on post-operative morbidity and mortality.
Overall, these data support the feasibility
and clinical utility of surgical treatment in the elderly patient. Series
like the present one demonstrate that with careful patient selection,
in centers with intermediate or higher volume, radical cystectomy appears
feasible. Long term oncological results are awaited.
REFERENCES
1. Konety BR, Dhawan V, Allareddy V, Joslyn SA. Impact
of hospital and surgeon volume on in-hospital mortality from radical cystectomy:
data from the health care utilization project. J Urol. 2005; 173: 1695-700.
2. Bochner BH, Kattan MW, Vora KC: Postoperative nomogram predicting risk
of recurrence after radical cystectomy for bladder cancer. J Clin Oncol.
2006; 24: 3967-72.
Dr.
Vincent Fradet & Dr. Badrinath R. Konety
Departments of Urology and Epidemiology
University of California, San Francisco
San Francisco, CA, USA
E-mail: vfradet@mac.com
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