Collaborative Review – Bladder CancerComplications Following Radical Cystectomy for Bladder Cancer in the Elderly
Introduction
In Europe, bladder cancer accounted for approximately 104 400 new cases and 36 500 cancer deaths in the year 2006 [1]. The incidence of bladder cancer increases distinctly with increasing age; the disease most commonly occurs beyond the 70th year of life [2]. Life expectancy is increasing, the proportion of elderly in the population is increasing in many parts of the world [3], and the invasiveness and complication rates of radical cystectomy are high. Consequently, treatment decisions for elderly patients with muscle-invasive or recurrent bladder cancer will constitute an important and difficult clinical challenge in the future.
Radical cystectomy is the standard treatment of localized muscle-invasive bladder cancer [4]. In elderly patients, concern has been expressed about the increased morbidity and mortality rates of radical cystectomy; however, advances in perioperative management have yielded considerable improvements in this field in recent decades [4], [5]. This article summarizes the current status of complication and mortality rates after radical cystectomy in elderly patients and investigates the available evidence for a possible relationship between age and the parameters of complications and functional results after radical cystectomy for muscle-invasive or recurrent bladder cancer.
Section snippets
Materials and methods
A literature review was performed in October and November 2008 using the US National Institutes of Health's PubMed database. The literature search was oriented toward recommendations for performing systematic reviews of randomized trials [6], with some modifications made according to the planned topic of this review article. The following combinations of key words were used: cystectomy AND complications, cystectomy AND complications AND elderly, cystectomy AND comorbidity, and cystectomy AND
Results
Including closely related work by the same research group, 42 studies were identified in the time period in question that investigated the relationship between age and radical cystectomy–related complications (Table 1). The sample sizes of these studies differed widely (range: 28–13 962). The rates of several complications as well as of mortality, continence, intensive care unit and hospital stay, metabolic acidosis, vitamin B12 deficiency, blood loss, reservoir capacity, reoperation rate, and
Who is considered elderly in the radical cystectomy setting?
Frequently, people aged ≥65 yr are considered elderly. Generally, in the health care setting, this population is often subdivided into young old (65–74 yr), old old (75–84 yr), and oldest old (≥85 yr) [60]. In the setting of radical cystectomy, the majority of authors used a limit of 75 yr of age to define elderly patients (Table 2). Explanations for choosing certain age-related stratification cutoffs, however, are not given in the related literature. It is conceivable that in some cases the
Conclusions
Age alone does not preclude radical cystectomy for muscle-invasive or recurrent bladder cancer or for certain types of urinary diversion. Perioperative morbidity and mortality, however, are increased and continence rates after orthotopic urinary diversion are impaired in the elderly population. Therefore, careful patient selection, treatment tailored to the needs and the physical capacity of the individual elderly patient, and active postoperative reeducation are particularly important if good
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