Morbidity and Quality of Life in Elderly Patients Receiving Ileal Conduit or Orthotopic Neobladder After Radical Cystectomy for Invasive Bladder Cancer

doi:10.1016/j.urology.2007.11.125

Urology

Volume 71, Issue 5, May 2008, Pages 919-923

https://doi.org/10.1016/j.urology.2007.11.125 Get rights and content

Abstract

Objectives

The objectives of the study were to evaluate morbidity, survival, and quality of life (QoL) in elderly patients with invasive bladder cancer who received an orthotopic neobladder or an ileal conduit.

Methods

The charts of 85 patients, aged 75 or older (median age 78), who had received an ileal conduit (n = 53) or an orthotopic neobladder (n = 32) after radical cystectomy at 3 Italian institutions in the period January 2000 to September 2004 were retrospectively reviewed. Perioperative and postoperative complications were recorded, as well as survival data at last follow-up. QoL was evaluated in 34 of 37 patients who were alive at the time of analysis by using the European Organisation for Research and Treatment of Cancer (EORTC) instruments quality of life questionnaire C30 (QLQ-C30) and QLQ-muscle-invasive bladder cancer module (QLQ-BLM).

Results

Multiple regression analysis showed that stage significantly affected survival whereas the type of urinary diversion did not. Global Health Status (GHS) scores in the neobladder group were higher than in the ileal conduit group but the difference was not statistically significant. The scores of all the QLQ multi-item scales and single-item measures were comparable in the 2 groups. Overall, 56% and 25% daytime and nighttime complete continence rates were observed in patients with an orthotopic neobladder.

Conclusions

The results of our retrospective analysis suggest that an orthotopic neobladder can be suitable for elderly patients with no additional morbidity compared with an ileal conduit. Both types of diversion seem to result in acceptable scores for most aspects of QoL, including urinary symptoms and continence rate. These figures may be helpful in the preoperative counselling of elderly patients with bladder cancer.

Section snippets

Study Design

The charts of 105 bladder cancer patients 75 years or older undergone radical cystectomy, followed by an ileal conduit or an orthotopic bladder substitution at 3 Italian institutions between January 2000 and October 2004 were reviewed. Eighty-five patients (53 ileal conduit and 32 bladder substitution, median age 78, range 75 to 88 years) of whom all preoperative (including American Society of Anesthesiologists [ASA] score) and follow-up information were available, entered the study, whereas

Results

Median age (range) was 77.5 years (75 to 82 years) in the neobladder group and 78.9 years (75 to 88 years) in the ileal conduit group (P = 0.03). No significant difference emerged in the clinical staging and gender distribution among patients in the 2 groups, whereas there was a significantly higher proportion of ASA scores¹⁷ III and IV in the group of patients receiving an ileal conduit. Table 1 reports the comparative data of the most relevant intraoperative and perioperative variables. No

Comment

Recent reports have shown that radical cystectomy can be safely performed in elderly individuals with low perioperative mortality, acceptable morbidity and in most cases without significant deviations from routine postoperative care.18, 19, 20 An ileal conduit is usually the urine diversion of choice in elderly patients.¹⁸ The feasibility of an orthotopic neobladder has been reported in 22 patients with no additional complications compared with an ileal conduit.¹¹ However, comparative data in

Conclusions

In our retrospective analysis, elderly patients receiving bladder substitution showed no difference in survival or severe complications when compared with a group of patients of similar age who had an ileal conduit. Similarly, no significant differences in QoL outcomes could be detected.

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2024, Radiotherapy and Oncology
Radical cystectomy (RC) is considered the standard treatment for muscle invasive bladder cancer (MIBC). However, RC is often burdened by significant impact on quality of life (QoL); Continence preserving methods (e.g., continent cutaneous urinary diversion and orthotopic neobladder-ONB), have been proposed as alternatives to improve postoperative QoL. Trimodal therapy (TMT) emerged as alternative to surgery. To assess the impact of these treatments from the patients’ perspective, we undertook a systematic review and meta-analysis of literature, focusing on studies reporting QoL data about each of the abovementioned approaches.
A systematic review was carried out including all prospective and retrospective studies enrolling patients treated with radical intent for non-metastatic MIBC from 1999 to 2021 (either RC or TMT). All studies included specifically reported QoL for one of the main treatment approaches explored (RC followed by ileal conduit urinary diversion-ICUD, ONB or TMT).
Pooled analysis for EORTC QLQ-C30 and BLM-30 questionnaires showed that ONB yielded a significant advantage only for Physical Functioning (pooled mean standardized difference −0.73 SD, p-value 0.019, I 2 = 93 %) and for Emotional Functioning (pooled mean standardized difference −0.16 SD, p-value 0.029, I 2 = 0 %). A trend in favour of higher mean reported values after TMT for Global Health Score, Physical Functioning and Role Functioning was found, if compared to both RC approaches.
Significant benefit for ONB if compared to ICUD was detected only for specific subdomains of QoL questionnaires. No direct comparison with TMT is available, but data suggest advantage of this approach when compared to both reconstructive scenarios.
Bladder preservation in older adults with muscle-invasive bladder cancer: A retrospective study with concurrent chemotherapy and twice-daily hypofractionated radiotherapy schedule
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Bladder cancer occurs mainly in older adults and surgery is not always possible when there are geriatric conditions and comorbidities. Trimodal treatment (TMT) combining trans-urethral resection of bladder tumour (TURBT) followed by concurrent chemoradiation (CRT) would be a curative alternative in such patients.
All consecutive patients 75 years of age and older with non-metastatic muscle-invasive bladder cancer (MIBC) treated with TMT by Georges Pompidou European Hospital team were retrospectively analysed. Induction CRT combined hypofractionated twice-daily radiotherapy targeting bladder and pelvis to a total dose of 24 Gy (Gy) with concurrent platinum salt and 5-fluorouracil. Consolidation CRT to a total dose of 44 Gy was proposed to patients with biopsy-proven complete response after induction phase and those with persistent tumour underwent salvage cystectomy. We assessed using Kaplan-Meier method overall survival (OS), cancer specific survival (CSS), invasive recurrence-free survival (IRFS), metastasis-free survival (MFS), survival with bladder preserved (SBP), and toxicities. With a Cox model for OS and the Fine Gray method of competing risk for secondary endpoints, we analysed in univariate (u) and multivariate (m) analysis the impact of tumour characteristics and patient profiles: gender, age, age-adjusted Charlson comorbidity index, polypharmacy, and malnutrition.
From 1988 to 2017, 85 patients were included. After induction, complete response rate was 83.5%. With a median follow-up of 63 months, 5 year-OS, CSS, IRFS, MFS and SBP were 61.0%, 77.6%, 71%, 82.9%, and 70.2% respectively. A persistent tumour after induction impacted SBP (SHRm 3.61; p = 0.004), CSS (SHRm 3.27; p = 0.023), and MFS (SHRm 3.68; p = 0.018). Late grade 3 urinary and gastrointestinal toxicities were 3.5% and 1.2%.
We report here the largest series of bladder preservation over 75 years in a curative intent. Outcomes and tolerance in selected older adults compared favourably with surgical series and with CRT studies using classical fractionation.
Midterm Health-related Quality of Life After Radical Cystectomy: A Propensity Score–matched Analysis
2020, European Urology Focus
Citation Excerpt :
First, we used the EORTC QLQ-C30, which is, unlike the EORTC QLQ-BLM30, not a bladder cancer–specific questionnaire and lacks additional information regarding body image, urostomy problems, and use of catheters. The QLQ-BLM30 has been used in several publications before, but is not validated [17–19]. Recently, the bladder-specific Bladder Utility Symptom Scale has been introduced, but has not been externally validated yet [20].
Radical cystectomy (RC) and urinary diversion affect various dimensions of patents’ health-related quality of life (HRQOL). Knowledge regarding patient-reported HRQOL following RC is mainly based on retrospective findings of cross-sectional studies.
To provide data from a large prospective propensity score–matched cohort with a systematic follow-up of up to 2 yr.
A total of 134 consecutive patients who underwent RC and ileal conduit (IC) or orthotopic ileal neobladder (ONB) urinary diversion in a tertiary care centre were prospectively enrolled, and a propensity score matching analysis based on American Society of Anesthesiologists score, age, and tumour stage was performed. Exclusion criteria encompassed age <30 yr and RC due to benign diseases. HRQOL was addressed with the validated European Organization for Research and
of Cancer QLQ-C30 questionnaire. HRQOL was assessed preoperatively, and at 3, 12, and 24 mo postoperatively. Of the nondeceased patients, 85.1% (IC) and 78.2% (ONB) completed the study.
RC.
The primary endpoint was good general HRQOL based on previously published cut-off values. Secondary endpoints encompassed the respective HRQOL domains. Univariate and multivariate analyses were performed using binary logistic regression models.
In the longitudinal analysis of RC patients, functioning and symptoms scores show a similar natural HRQOL course for IC and ONB patients. After 24 mo, general HRQOL was significantly higher in the ONB subcohort (60.5 vs 73.6, p = 0.013). Good general HRQOL was reached by 32.4 (IC) versus 61.1% (ONB; p = 0.019). In the multivariable analysis, ONB was not an independent predictor of good HRQOL (odds ratio 2.211, 95% confidence interval 0.684–7.150, p = 0.185). Limitations include the nonbladder specificity of the QLQ-C30 questionnaire and the small sample size.
The current study provides prospective data from a unique propensity score–matched contemporary patient cohort. We display the natural history of general HRQOL and its subdomains without observing significantly higher midterm postoperative HRQOL in patients undergoing continent urinary diversion in the multivariable analysis.
We analyse the health-related quality of life (HRQOL) of European patients who underwent radical cystectomy due to bladder cancer and found that HRQOL was slightly better for orthotopic ileal neobladder than for ileal conduit urinary diversion after 24 mo.
Patient-reported Quality of Life Outcomes in Patients Treated for Muscle-invasive Bladder Cancer with Radiotherapy ± Chemotherapy in the BC2001 Phase III Randomised Controlled Trial[Formula presented]
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BC2001, the largest randomised trial of bladder-sparing treatment for muscle-invasive bladder cancer, demonstrated improvement of local control and bladder cancer–specific survival from the addition of concomitant 5-fluorouracil and mitomycin C to radiotherapy.
To determine the impact of treatment on the health-related quality of life (HRQoL) of BC2001 participants.
458 UK patients with T2-T4a N0 M0 transitional cell carcinoma of the bladder.
Patients were randomised to the chemotherapy comparison (radiotherapy, 178, or chemoradiotherapy, 182); and/or to the radiotherapy comparison (standard, 108, or reduced high-dose volume radiotherapy, 111).
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Data were available for 331 (92%) and 204 (93%) participants at baseline and for 192 (54%) and 114 (52%) at 12 months for the chemotherapy and radiotherapy comparisons, respectively. HRQoL declined at EoT (BLCS –5.06 [99% confidence interval: –6.12 to –4.00, p < 0.001]; overall FACT-B TOTAL score –8.22 [–10.76 to –5.68, p < 0.01]), recovering to baseline at 6 months and remaining similar to baseline subsequently. There was no significant difference between randomised groups at any time point.
Immediately following (chemo)radiotherapy, a significant proportion of patients report declines in HRQoL, which improve to baseline after 6 months. Two-thirds of patients report stable or improved HRQoL on long-term follow-up. There is no evidence of impairment in HRQoL resulting from the addition of chemotherapy.
Quality of life of bladder cancer patients treated with radiotherapy ± chemotherapy deteriorates during treatment, but improves to at least pretreatment levels within 6 months. Addition of chemotherapy to radiotherapy does not affect patient-reported quality of life.
Patient Selection and Counseling for Urinary Diversion
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Citation Excerpt :
However, physiologic age appears to be more closely associated with patient outcome when compared with chronologic age. For this reason, many centers advocate that no age limit should apply and that patient selection should instead be determined by surgical fitness, functional status, and motivation.41,42 There are several important contraindications to CDs in general, as well as those unique to ODs.
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OncologyMorbidity and Quality of Life in Elderly Patients Receiving Ileal Conduit or Orthotopic Neobladder After Radical Cystectomy for Invasive Bladder Cancer

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Study Design

Results

Comment

Conclusions

Estimates of the cancer incidence and mortality in Europe in 2006

Ann Oncol

Cystectomy in the elderly

Semin Urol Oncol

Precystectomy nomogram for prediction of advanced bladder cancer stage

Eur Urol

Delay in the surgical treatment of bladder cancer and survival: systematic review of the literature

Eur Urol

Radical cystectomy in patients older than 75 years: assessment of morbidity and mortality

Eur Urol

Radical cystectomy is safe in elderly patients at high risk

J Urol

Benefit of radical cystectomy in the elderly patient with significant co-morbidities

Urol Oncol

Quality of life with bladder reconstruction

Semin Urol Oncol

Health related quality of life after radical cystectomy and urinary diversion for bladder cancer: a systematic review and critical analysis of the literature

J Urol

Health related quality of life assessments for patients with bladder cancer

J Urol

A multicenter study of the morbidity of radical cystectomy in select elderly patients with bladder cancer

J Urol

Continent urinary reconstruction versus ileal conduit: a contemporary single-institution comparison of perioperative morbidity and mortality

Urology

The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology

J Natl Cancer Inst

Oncology
Morbidity and Quality of Life in Elderly Patients Receiving Ileal Conduit or Orthotopic Neobladder After Radical Cystectomy for Invasive Bladder Cancer