Evaluating Surgical Approaches in Advanced Age: A Propensity-Matched Analysis of Postoperative Morbidity and...

Introduction: The optimal surgical approach for elderly bladder cancer patients remains controversial. We compared perioperative morbidity and short-term outcomes in patients aged ≥ 75 years undergoing open radical cystectomy (ORC) versus robot-assisted radical cystectomy (RARC). Methods: A retrospective, multicenter cohort study was performed including 179 patients aged ≥ 75 years, of whom 101 underwent RARC between 2021 and 2025, and 78 underwent ORC between 2016 and 2020. After 1:1 propensity score matching, 138 patients were analyzed to assess perioperative complications and short-term postoperative outcomes. Pathological outcomes, including pathological stage, tumor grade, lymph node status, and positive surgical margins, were additionally compared between groups. Propensity score matching was performed based on age, body mass index (BMI), pathological stage, comorbidities, prior chemotherapy, and type of urinary diversion. Results: Following propensity score matching, RARC was associated with longer operative time (332 vs. 247 min; p < 0.001) but resulted in significantly lower blood loss (310 vs. 743 mL; p < 0.001), reduced transfusion rates, shorter length of hospital stay (p < 0.001), and fewer overall intraoperative complications (8.7% vs. 18.8%; p = 0.04). Patients undergoing RARC also experienced lower rates of any complications (43.5% vs. 62.3%; p = 0.02) and major complications (Clavien-Dindo III-V: 11.6% vs. 27.5%; p = 0.03). Postoperative mortality was low in both groups and did not differ significantly between RARC and ORC (1.4% vs. 2.9%; p = 1.00). In multivariate analysis, surgical approach independently predicted major complications, with RARC conferring a significantly lower risk (OR 0.75; 95% CI 0.51-0.88; p = 0.04). Analysis of the learning curve showed a significant reduction in major complications over time for RARC (OR 0.68; 95% CI 0.53-0.93; p = 0.01) but not for ORC. Conclusions: RARC offers superior perioperative outcomes, including reduced blood loss, shorter hospitalization, and lower rates of major complications, without differences in short-term pathological outcomes. These data support RARC as a safe and effective option for elderly patients undergoing radical cystectomy.