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

Although recent series have demonstrated that radical cystectomy can be safely performed in elderly patients, few if any, have examined the long-term success of this procedure. We sought to determine the long-term benefit and survival outcomes after radical cystectomy in the elderly, high operative risk patient. We reviewed the records of all patients undergoing radical cystectomy between July 1994 and January 2000. Of these 382 patients, we identified 38 patients with transitional cell carcinoma who met our predetermined selection criteria of elderly, high peri-operative risk patients [age > or = 75 years and American Society of Anesthesiologists (ASA) classification > or = 3]. We analyzed patient characteristics, presenting symptoms, pathology, outcomes, and survival. Median age was 79 years (75-87 years). All but a single patient underwent surgery for symptomatic disease. No patient died in the early perioperative period. At a mean follow-up of 22 months (3-90 months), 11/38 (29%) patients are alive. Of the patients with < or = pT2B pathology, 9/27 (33%) are alive and are disease-free. There are 2/11 patients (18%) with > or = pT3 pathology still alive with 1 of those patients (pT4a) alive with disease 34 months after his radical cystectomy. Kaplan-Meier survival curves demonstrate that patients with organ confined disease (< or = pT2B) had a significantly longer mean overall survival than patients with nonorgan confined disease (> or = pT3): 31 months vs. 18 months, P = 0.046. Cause of death was known in 17 patients, with the majority (14/17) because of bladder cancer. However, there were no local recurrences, and palliative goals were achieved in all patients. Our results validate radical cystectomy as a safe and effective treatment choice in the elderly patient with significant co-morbidities. These patients, most of whom are symptomatic, can achieve palliation of their symptoms, local control, and long term survival, especially if their bladder cancer is organ confined. Reluctance to offer timely, aggressive local therapy may compromise ultimate survival, even amongst high operative risk, elderly patients.