Jill Stein

May 26, 2011

May 26, 2011 (Washington, DC) — Robot-assisted radical cystectomy is effective and safe in patients 80 years and older who have muscle-invasive bladder cancer, with results on a par with those in younger patients, researchers reported here at the American Urological Association (AUA) 2011 Annual Scientific Meeting.

A team from Weill Cornell Medical College in New York City found that the minimally invasive procedure provided similar disease control and similar major perioperative and postoperative complications in older and younger patients, despite a higher rate of comorbidities in the older group.

"Age is often cited as a risk factor for complications after cystectomy," Douglas S. Scherr, MD, the Ronald Stanton Clinical Scholar in Urology and clinical director of urologic oncology, told Medscape Medical News. "Older patients are typically denied a cystectomy — the treatment standard — and are instead 'steered' toward a bladder-sparing approach involving radiation and chemotherapy or no treatment at all. This is unfortunate, given that they are much more likely to die of bladder cancer without bladder removal."

Advanced age is not a reason to exclude an otherwise suitable patient from a cystectomy, provided that the patient has undergone rigorous medical clearance, he said. "We think that a minimally invasive approach is preferable to the standard open-surgery procedure."

Increase in Bladder Cancer

There are roughly 56,000 new cases of bladder cancer each year, most in patients 55 years and older, Dr. Scherr reported, and the prevalence is expected to increase with the aging of the population. "Most of the baby boom population — which is the fastest growing group — is now reaching their 80s, and most of them have a significant smoking history," he said. "So we anticipate seeing a much larger percentage of patients over age 80 presenting with bladder cancer."

The study examined 162 consecutive patients with muscle-invasive bladder cancer on whom Dr. Scherr performed robotic cystectomy over a recent 4-year period. Overall, 39 (24%) patients were 80 years or older and had been medically cleared for a surgical intervention. Most patients were men.

There were more American Society of Anesthesiology (ASA) scores above 2 in the older than in the younger group (72% vs 43%; P = .002) and more Charlson-Romano scores above 2 (60% vs 33%, P = .003). In addition, more older than younger patients had received neoadjuvant chemotherapy (7% vs 27%; P = .012) and had previously undergone radiation therapy (18% vs 11%; P = .222). Fewer older patients had previously undergone abdominal surgery (44% and 45%; P = .902).

Median operating time was shorter in the older than in the younger patients (5.4 vs 6.3 hours; P < .001), and median estimated blood loss was less in the older patients (300 mL vs 400 mL; P = .069). All octogenarians underwent ileal conduit diversion, whereas only half of younger patients did (P < .001).

There were no differences in pathology between the 2 groups after robotic surgery.

Good Outcomes With Robotic Procedure

Mean overall survival was 15 months in the older patients and 20 months in younger patients (P = .001). "Obviously, older patients had a shorter overall survival because they are older and you can't live forever," Dr. Scherr explained. The groups were similar with respect to cancer-specific survival, with a roughly 75% survival rate at 90-day follow-up.

Only 18% of older patients had major complications at 90-day follow-up, compared with 23% of younger patients (P = .52). "For this heavily pretreated elderly sick population, this is a dramatic improvement over what you see in most series of open surgeries in both elderly and nonelderly groups," he said.

Dr. Scherr emphasized that strict medical clearance is indicated prior to a robotic cystectomy. "Obviously, all patients need extensive cardiac clearance involving a stress test and echocardiogram," he said. "If they have a pulmonary issue, they may need a pulmonary assessment before the procedure. Also, particularly with robotics, some very obese patients may not be candidates because the procedure is performed in a position that might compromise their pulmonary status during the case; although some obese patients may not be candidates, the decision as to who is suitable is made on a case-by-case basis."

Finally, this study showed that results with robotic cystectomy in octogenarians rival those in younger patients. Earlier research by the same investigators showed that robotic surgery significantly decreased the rates of major and minor complications, compared with radical cystectomy.

"We think it's clear that robotic surgery is superior to the standard radical cystectomy," Dr. Scherr said.

Jeffrey Holzbeierlein, MD, who is on the AUA Public Media Committee and is the John W. Weigel Endowed Associate Professor of Urology and director of urologic oncology at the University of Kansas Medical Center in Kansas City, told Medscape Medical News that the study is limited by its nonrandomized design. "There's an inherent bias in a nonrandomized trial, and clearly the investigators were selecting the healthy 80 year olds for inclusion in the study and excluding the 80 year olds with a poor performance status," he said.

He also pointed out that he would have liked "to have seen longer follow-up data, since older patients are obviously more likely not to return home after a procedure, and instead go to a nursing home, skilled nursing facility, or some other such place. If that's the case [in this study], we have data showing that those patients actually have much worse outcomes than those who do not go to such facilities. So we need more data on where patients are going after their operation."

Dr. Holzbeierlein said that the "medically cleared" octogenarian with muscle-invasive bladder cancer should not be excluded from a cystectomy. However, he explained, "there's really no difference in outcomes between open and robotic procedures. . . . There's less blood loss with the robotic procedure, but . . . [in expert hands], there isn't a large difference [in blood loss] between the open and robotic procedures."

Dr. Scherr and Dr. Holzbeierlein have disclosed no relevant financial relationships.

American Urological Association (AUA) 2011 Annual Scientific Meeting: Abstract 481. Presented May 16, 2011.


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