Perioperative and oncologic outcomes of extirpative surgery for upper tract urothelial cancer in octogenarians

Upper tract urothelial carcinoma (UTUC) predominantly affects older patients. We evaluated whether advanced age influences perioperative and oncologic outcomes following radical surgery for UTUC.

We analyzed a multi-institutional cohort of 2,380 patients treated for UTUC with radical nephroureterectomy or partial ureterectomy between 2006 and 2023. Patients were stratified by age: <60 (n = 380), 60 to 70 (n = 741), 70 to 80 (n = 849), and >80 years (n = 410). Outcomes assessed included perioperative complications, pathologic features, and survival metrics across each age group and were compared using Kruskal-Wallis rank sum test. Cox proportional hazards models were used to evaluate factors associated with recurrence, metastasis, and mortality. In addition, Fit and Gray competing risk model was used to assess cancer-specific mortality.

Elderly patients demonstrated higher American Society of Anesthesiologists scores, comorbidity burden, and decreased renal function (all P < 0.001). While clinical stage was similar among age groups, older patients more frequently exhibited advanced pathologic T-stage (P = 0.04), higher grade (P = 0.007), nodal involvement (P = 0.002), and lymphovascular invasion (P = 0.004). While overall complications increased with age (P < 0.001), rates of major complications (≥Clavien-Dindo III) remained similar (P = 0.19). Perioperative chemotherapy utilization declined with age (P < 0.001). On univariate Cox regression analysis, advanced age (>80 years) was associated with increased risk of intravesical recurrence, metastasis, overall mortality, and cancer-specific mortality; however, on multivariable analysis, age >80 years remained independently associated with increased risk of metastasis and overall mortality but not intravesical recurrence or cancer-specific mortality.

Advanced age alone should not contraindicate surgical intervention for UTUC. Elderly patients exhibit more aggressive UTUC pathologies but with similar cancer-specific survival and comparable rates of major complications postoperatively compared to their younger counterparts. Results support individualized treatment selection based on comprehensive patient assessment rather than age alone.