Laparoscopic Radical Cystectomy in the Elderly – Results of a Single Center LRC only Series

Hermans, Tom J. N.; Fossion, Laurent M. C. L.; Verhoeven, Rob; Horenblas, Simon

doi:10.1590/S1677-5538.IBJU.2015.0419

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Original Article • IBJUInt. braz j urol 42 (06) • Nov-Dec 2016 • https://doi.org/10.1590/S1677-5538.IBJU.2015.0419 copy

Laparoscopic Radical Cystectomy in the Elderly – Results of a Single Center LRC only Series

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To compare outcome of laparoscopic radical cystectomy (LRC) with ileal conduit in 22 elderly (≥75 years) versus 51 younger (<75 years) patients.

Materials and Methods:

Analysis of prospectively gathered data of a single institution LRC only series was performed. Selection bias for LRC versus non-surgical treatments was assessed with data retrieved from the Netherlands Cancer Registry.

Results:

Median age difference between LRC groups was 9.0 years. (77.0 versus 68.0 years). Both groups had similar surgical indications, body mass index and gender distribution. Charlson Comorbidity Index score was 3 versus 4 in ≥50% of younger and elderly patients. Median operative time (340 versus 341 min) and estimated blood loss (<500 versus >500mL) did not differ between groups. Median total hospital stay was 12.0 versus 14.0 days for younger and elderly patients. Grade I-II 90-d complication rate was higher for elderly patients (68 versus 43%, p=0.05). Grade III-V 90-d complication rate was equal for both groups (23 versus 29%, p=0.557). 90-d mortality rate was higher for elderly patients (14 versus 4%, p=0.157). Median follow-up was 40.0 months for younger and 57.0 months for elderly patients. Estimated overall and cancer-specific survival at 5years. was 46% versus 35% and 64% versus 64% for younger and elderly patients respectively.

Conclusions:

Our results suggest that LRC is feasible in elderly patients, where a non-surgical treatment is usually favoured.

Key words:
Cystectomy; Geriatrics; Minimally Invasive Surgical Procedures; Survival; Urinary Bladder Neoplasms

		Total N = 73	< 75 years N = 51	≥ 75 years N = 22	P-value
Gender, n (%)
	Male	59 (80)	42 (82)	17 (77)	0.613^a a Chi-square test;
	Female	14 (19)	9 (18)	5 (23)
Age (year), median (range)		70.1 (42–86)	68.0 (42–74)	77.0 (75-86)	<0.001^b b Mann-Whitney U test;
BMI^e e Body Mass Index; (kg/m²), median (range)		25.7 (16.0-37.6)	25.4 (16.0-37.6)	26.4 (17.3-36.0)	0.799^c c Independent sample T test;
CCI^f f Charlson Comorbidity Index; (age included), (range)		≥3.0 in 50% of	≥3.0 in 50% of	≥4.0 in 50% of	<0.001^b b Mann-Whitney U test;
		patients (0-8)	patients (0-5)	patients (3-8)
CCI^f f Charlson Comorbidity Index; (age score excluded), (range)		≥0.0 in 50% of	≥0.0 in 50% of	≥1.0 in 50% of	0.028^b b Mann-Whitney U test;
		patients (0-5)	patients (0-3)	patients (0-5)
Indication, n (%)
	NMIBC^g g (N) MIBC = (Non) Muscle Invasive Bladder Cancer;	16 (22)	9 (18)	7 (32)	0.179^a a Chi-square test;
	MIBC^g g (N) MIBC = (Non) Muscle Invasive Bladder Cancer;	57 (78)	42 (82)	15 (68)
Neoadjuvant chemotherapy, n (%)		2 (3)	2 (4)	0 (0)	1.0^d d Fischer's exact test;
Operative time (min), median (range)		340 (260-780)	340 (260-510)	341.0 (271-780)	0.852^b b Mann-Whitney U test;
Estimated blood loss (mL), median (range)		500 (100-3300)	500 (100-3300)	500 (100-2000)	0.346^b b Mann-Whitney U test;
Pre-operative Hemoglobin (mmoL/L) median (range)		8.4 (5.1-10.3)	8.8 (5.10-10.3)	7.6 (6.0-7.6)	0.004^c c Independent sample T test;
Transfusions during hospital stay, n (%)		21 (29)	10 (20)	11 (50)	0.01^a a Chi-square test;
Conversions, n (%)		0 (0)	0 (0)	0 (0)	>0.05^d d Fischer's exact test;
Intensive care unit admissions, n (%)		16 (22)	10 (20)	6 (27)	0.468^a a Chi-square test;
Total hospital stay (days), median (range)		13.0 (6-147)	12.0 (6-147)	14.0 (8-28)	0.133^b b Mann-Whitney U test;
Mortality, n (%)
	30 days	1 (1)	1 (2)	0 (0)	1.0^d d Fischer's exact test;
	90 days	5 (7)	2 (4)	3 (14)	0.157^d d Fischer's exact test;
Complications 90-days n (%)
	Clavien I/ II (incl. transfusions)	37 (51)	22 (43)	15 (68)	0.05^a a Chi-square test;
	Clavien I/ II (excl. transfusions)	26 (36)	15 (29)	11 (50)	0.092^a a Chi-square test;
	Clavien III/ IV/ V	20 (27)	15 (29)	5 (23)	0.557^a a Chi-square test;

Overall (n=208)
	Cystectomy	Radiotherapy and/ or chemotherapy	Transurethral resection and/ or intravesical therapy	No treatment	Unknown
N (%)	77 (37)	30 (14)	90 (43)	9 (4)	2 (1)
Age year ^a a Independent sample T-test for age at cystectomy vs. radiotherapy and/ or chemotherapy p=0.016; (median)	69.0	74.0	74.0	84.0	70.0
Comorbidity score ^b b Independent sample T-test for comorbidity at cystectomy vs. radiotherapy and/ or chemotherapy p=0.008;	≥1.0 in 50% of patients	≥2.0 in 50% of patients	≥1.0 in 50% of patients	≥3.0 in 50% of patients	-
Patients aged ≥ 75 years (n=85)
	Cystectomy	Radiotherapy and/ or chemotherapy	Transurethral resection and/ or intravesical therapy	No treatment	Unknown
N (%)	22 (26)	13 (15)	44 (52)	6 (7)	-
Age year ^c c Mann-Whitney U test for age at cystectomy vs. radiotherapy and/ or chemotherapy p<0.001; (median)	77.5	85.0	82.0	87.5
Comorbidity score ^d d Mann-Whitney U test for comorbidity at cystectomy vs. radiotherapy and/ or chemotherapy p=0.334	≥2.0 in 50% of patients	≥2.0 in 50% of patients	≥2.0 in 50% of patients	≥2.5 in 50% of patients	-

<75 years (N=51)
Clavien grade	Complication	Cases (N)	Management
Peroperative
I	Damage to iliac vein	1	Laparoscopic suturing
I	Rectal lesion	3	Laparoscopic suturing
Iva	Rupture of lumbar vein	1	Laparoscopic suturing
≤ 90 days
I	Anemia	10	Blood transfusion
I	Delirium	1	Antipsychotics
I	Wound infection	2	Antibiotics and bedside management
II	Acute myocardial infarction	1	Pharmacological treatment
II	Deep venous thrombosis	1	Pharmacological treatment
II	Exacerbation COPD	1	Pharmacological treatment
II	Pneumonia	4	Antibiotics
II	Prolonged bowel ileus (no acceptance of oral intake 5 days after surgery)	6	Conservative
II	Urinary tract infection/ sepsis	4	Antibiotics
IIIa	Ureteroileal obstruction with or without infection	2	Nephrostomy (and antibiotics)
IIIa	Lymphatic leakage with or without infection	2	Percutaneous drainage
IIIa	Necrosis of praeputium penis	1	Surgery
IIIb	Compartment syndrome lower leg	2	Surgery
IIIb	Iatrogenic corpus alienum (drain) in the abdomen	1	Surgery
IIIb	Iatrogenic defect ileal conduit after correction incisional hernia	1	Surgery
IIIb	Iatrogenic pneumothorax	1	Surgery
IIIb	Incisional hernia (+ after relaparotomy)	3	Surgery
IIIb	Rectourethral fistula	2	Surgery
Iva	Acute tubular necrosis	1	Haemodialysis
Iva	Ileal anastomotic leakage	2	Surgery
IVb > V	Pneumosepsis	1	-
IVb > V	Candida sepsis	1	-
≥75 years (N=22)
Peroperative
I	Rectal lesion	1	Laparoscopic suturing
I	Damage to iliac vein	1	Laparoscopic suturing
≤ 90 days
I	Anemia	11	Blood transfusion
I	Delirium	1	Antipsychotics
I	Temporary paresis of right upper arm	1	Conservative
I	Wound infection	1	Antibiotics and bedside management
II	Atrial flutter	1	Pharmacological treatment
II	Pneumonia	3	Antibiotics
II	Prolonged bowel ileus (no acceptance of oral intake 5 days after surgery)	2	Conservative
II	Urinary tract infection/ sepsis	2	Antibiotics
IIIa	Uretero-ileal obstruction with or without infection	4	Nephrostomy (and antibiotics)
IIIa	Lymphatic leakage with or without infection	1	Percutaneous drainage
IIIb	Rectourethral fstula	1	Surgery
Iva	Rabdomyolysis	1	Conservative

		Total N = 73	< 75 years N = 51	≥ 75 years N = 22	P-value
Histology, n (%)
	Urothelial carcinoma	71 (98)	50 (98)	21 (96)	0.515^a a Fischer's exact test;
	Squamous cell carcinoma	1 (1)	0 (0)	1 (4)
	Bladder sarcoma	1 (1)	1 (2)	0 (0)
Organ confining, n (%)
	Organ-confined disease (≤ pT2)	38 (52)	28 (55)	10 (45)	0.458^b b Chi-square test;
	Non organ confned disease (>pT3)	35 (48)	23 (45)	12 (55)
Lymph nodes removed, mean		14.9 (1-36)	15.7 (1-32)	13.3 (3-36)	0.063^c c Mann-Whitney U test
Lymph node involvement, n (%)
	pN0	50 (69)	35 (68)	15 (68)
	pN1	9 (12)	5 (10)	4 (18)	0.558^b b Chi-square test;
	pN2 or N3	13 (18)	10 (20)	3 (14)
	unknown	1 (1)	1 (2)	0 (0)
Positive surgical margins, n (%)		9 (12)	4 (8)	5 (23)	0.118^a a Fischer's exact test;
Median follow-up, months (range)		46.0 (0-97)	40.0 (0-97)	57.0 (1-75)	0.445^c c Mann-Whitney U test

	Age	CCI^a a Charlson Comorbidity Index	Pathology	Period to death	Cause of death
1	77	6	pT3N1 R0	< 90-d	Metastatic disease
2	79	4	pT3N1 R0	< 90-d	Gastro-enteritis with dehydration
3	80	5	pT3N2 R0	< 60-d	Metastatic disease
4	67	3	pT2N0 R0	< 30-d	Postoperative pneumosepsis
5	70	3	pT4N1 R1	< 60-d	Metastatic disease

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[1] Correspondence address: Tom J. N. Hermans, MD, Department of Urology, Maxima Medical Center Veldhoven, Veldhoven, The Netherlands, De run 4600, Veldhoven 5504 DB, Netherlands, E-mail: tjnhermans@gmail.com