Cytoreductive nephrectomy in the elderly: a population-based cohort from the USA

Study Type - Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? While cytoreductive nephrectomy is associated with a survival benefit in the context of metastatic renal cell carcinoma, the rates of morbidity and perioperative mortality remain non-negligible. For example, perioperative mortality may be as high as 21% in elderly patients. The study shows that perioperative death amongst the elderly was substantially lower than what was previously reported from a single institutional report. Nonetheless, postoperative adverse outcomes were non-negligible in elderly patients relative to their younger counterparts. In consequence, these rates should be discussed at informed consent and a rigorous patient selection remains essential.

• To examine the rate of perioperative mortality (PM), and other adverse outcomes in 'elderly' patients treated with cytoreductive nephrectomy (CNT).

• Patients who underwent CNT for metastatic renal cell carcinoma were abstracted from the Nationwide Inpatient Sample (1998-2007). 'Elderly' was defined as ≥ 75 years, according to previous definition. • Endpoints consisted of PM, intraoperative and postoperative complications, blood transfusions and length of stay. • We adjusted for the effect of elderly status within five separate logistic regression models. Covariates consisted of comorbidity, race, gender, year of surgery and hospital region.

• Overall, CNT was performed in 504 (15.3%) elderly patients and in 2796 (84.7%) 'younger' patients (<75 years). • The rate of PM was 4.8% in elderly patients vs 1.9% in the younger patients (P < 0.001). Similarly, the rates of blood transfusions (29.8 vs 21.5%), postoperative complications (27.8 vs 22.8%), and prolonged length of stay (≥ 8 days) were higher in the elderly (45.0 vs 32.0%; all P < 0.001). • In multivariable analyses, elderly patients were 2.2-, 1.5-, and 1.6 fold more likely to experience PM, to receive a blood transfusion and to be hospitalized ≥ 8 days than the younger patients.

• Although the rate of PM was substantially lower than 21%, elderly patients are significantly more likely to die after this type of surgery, to receive a transfusion, and to experience a prolonged length of stay. • These facts and figures should be discussed at informed consent and a rigorous patient selection is essential.