Objective: A potential strategy to decrease the high complication rate of radical cystectomy (RC) in the elderly is to avoid the use of bowel for urinary diversion. The aim of this study was to address this issue in a multicentre study of patients aged ≥75 years. Patients and Methods: We performed a retrospective, multicentre study of a consecutive series of patients aged ≥75 years who underwent RC for muscle-invasive bladder cancer between 2006 and 2010. Medical, surgical and wound complications were graded according to the modified Clavien-Dindo classification. Results: A total of 256 patients (68% men, mean age 79.6 years) were analysed. 204 (80%) patients received a urinary diversion with use of bowel and 52 (20%) a ureterocutaneostomy (UC). Patients with UC were older (82.0 vs. 78.9 years, p < 0.001) and had a higher ASA score (2.6 vs. 2.3, p = 0.007), while the mean Charlson score was lower (4.2 vs. 5.6, p < 0.001). Patients with UC had a shorter operating time (279 vs. 311 min, p = 0.002) and a shorter period in the intensive care unit (0.9 vs. 2.2 days). The overall rate of severe complications graded as Clavien III-V was significantly lower in the UC group (11.5%) as compared to patients receiving bowel for urinary diversion (25.0%) (p = 0.003). Severe (Clavien grade III-V) medical (3.9 vs. 10.3%) and surgical (2.1 vs. 14.1%) complications were all less frequent in the UC group. Inpatient, 30- and 90-day mortality was 5.8, 7.7 and 17.3% in the UC group as compared to 3.9, 5.9 and 6.9% in the bowel cohort, respectively. Conclusion: UC following RC is associated with a lower complication rate in geriatric patients. The constantly increasing cohort of geriatric, multimorbid patients requiring cystectomy might justify reconsideration of this form of diversion.

Keywords:
Radical cystectomy, Urinary diversion, Complications, Mortality
1.
Ferlay J, Parkin DM, Steliarova-Foucher E: Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer 2010;46:765-781.
2.
Madersbacher S, Hochreiter W, Burkhard F, Thalmann GN, Danuser H, Markwalder R, Studer UE: Radical cystectomy for bladder cancer today - a homogeneous series without neoadjuvant therapy. J Clin Oncol 2003;21:690-696.
3.
Froehner M, Brausi MA, Herr HW, Muto G, Studer UE: Complications following radical cystectomy for bladder cancer in the elderly. Eur Urol 2009;56:443-454.
4.
Prout GR, Wesley MN, Yanick R, Ries LA, Havlik RJ, Edwards BK: Age and comorbidity impact surgical therapy in older bladder carcinoma patients: a population-based study. Cancer 2005;104:1638-1647.
5.
Fairey A, Chetner M, Metcalfe J, Moore R, Todd G, Rourke K, Voaklander D, Estey E: Associations among age, comorbidity and clinical outcomes after radical cystectomy: results from the Alberta Urology Institute radical cystectomy database. J Urol 2008;180:128-134.
6.
Chamie K, Hu B, Devere White RW, Ellison LM: Cystectomy in the elderly: does survival benefit in younger patients translate to the octogenarians? BJU Int 2008;102:284-290.
7.
Clark PE, Stein JP, Groshen SG, Cai J, Miranda G, Lieskovsky G, Skinner DG: Radical cystectomy in the elderly: comparison of clinical outcomes between younger and older patients. Cancer 2005;104:36-43.
8.
Donat SM, Siegrist T, Cronin A, Savage C, Milowsky MI, Herr HW: Radical cystectomy in octogenarians - does morbidity outweigh the potential survival benefits? J Urol 2010;183:2171-2177.
9.
Liberman D, Lughezzani G, Sun M, Alasker A, Thuret R, Abdollah F, Budaus L, Widmer H, Graefen M, Montorsi F, Shariat SF, Perrotte P, Karakiewicz PI: Perioperative mortality is significantly greater in septuagenarian and octogenarian patients treated with radical cystectomy for urothelial carcinoma of the bladder. Urology 2011;77:660-666.
10.
Hollenbeck BK, Miller DC, Taub D, Dunn RL, Underwood W 3rd, Montie JE, Wei JT: Aggressive treatment for bladder cancer is associated with improved overall survival among patients 80 years old or older. Urology 2004;64:292-297.
11.
Nielsen ME, Shariat SF, Karakiewicz PI, Lotan Y, Rogers CG, Amiel GE, Bastian PJ, Vazina A, Gupta A, Lerner SP, Sagalowsky AI, Schoenberg MP, Palapattu GS; Bladder Cancer Research Consortium (BCRC): Advanced age is associated with poorer bladder cancer-specific survival in patients treated with radical cystectomy. Eur Urol 2007;51:699-706.
12.
Roghmann F, Noldus J, von Bodman C, Holz A, Brock M, Palisaar J: Cystectomy in elderly patients: analysis of complications using the Clavien-Dindo classification. Urologe A 2012;51:1386-1392.
13.
Wehrberger C, Berger I, Marszalek M, Ponholzer A, Wehrberger M, Rauchenwald M, Madersbacher S: Bladder preservation in octogenarians with invasive bladder cancer. Urology 2010;75:370-375.
14.
Berger I, Martini T, Wehrberger C, Comploj E, Ponholzer A, Wolfgang M, Breinl E, Dunzinger M, Hofbauer J, Höltl W, Jeschke K, Krause S, Kugler W, Pauer W, Rauchenwald M, Pycha A, Madersbacher S: Perioperative complications and 90-day mortality of radical cystectomy in the elderly (75+): a retrospective, multicentre study. Urol Int 2014;93:296-302.
15.
Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M: The Clavien-Dindo classification of surgical complications: five year experience. Ann Surg 2009;250:187-196.
16.
Dindo D, Demartines N, Clavien PA: Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-213.
17.
Pycha A, Comploj E, Martini T, Trenti E, Mian C, Lusuardi L, Lodde M, Mian M, Palermo S: Comparison of complications in three incontinent urinary diversions. Eur Urol 2008;54:825-832.
18.
Gschwend JE, Hautmann RE, Volkmer BG: Radical cystectomy and urinary diversion in elderly patients with increased comorbidity. Urologe A 2004;43:930-934.
19.
Deliveliotis C, Papatsoris M, Dellis A, Liakouras C, Skolarikos A: Urinary diversion in high-risk elderly patients: modified cutaneous ureterostomy or ileal conduit? Urology 2005;66:299-304.
20.
De Nunzio C, Cicione A, Leonardo F, Rondoni M, Franco G, Cantiani A, Tubaro A, Leonardo C: Extraperitoneal radical cystectomy and ureterocutaneostomy in octogenarians. Int Urol Nephrol 2011;43:663-667.
21.
Yoshimura K, Maekawa S, Ichioka K, Terada N, Matsuta Y, Okubo K, Arai Y: Tubeless cutaneous ureterostomy: the Toyoda method revisited. J Urol 2001;165:785-788.
22.
Bartsch G, Gust K, Vallo S, Bartsch C, Tsaur I, Mani J, Haferkamp A: Cystectomy in the elderly patient. Urologe A 2013;52:821-826.
23.
Saika T, Arata R, Tsushima T, Nasu Y, Suyama B, Takeda K, Ebara S, Manabe D, Kobayashi T, Tanimoto R, Kumon H; Okayama Urological Research Group: Health-related quality of life after radical cystectomy for bladder cancer in elderly patients with an ileal conduit, ureterocutaneostomy, or orthotopic urinary reservoir: a comparative questionnaire survey. Acta Med Okayama 2007;61:199-203.
24.
Vakalopoulos I, Dimitriadis G, Anastasiadis A, Gkotsos G, Radopoulos D: Does intubated uretero-ureterocutaneostomy provide better health-related quality of life than orthotopic neobladder in patients after radical cystectomy for invasive bladder cancer? Int Urol Nephrol 2011;43:743-748.
25.
Turgeon GA, Souhami L, Cury FL, Faria SL, Duclos M, Sturgeon J, Kassouf W: Hypofractionated intensity modulated radiation therapy in combined modality treatment for bladder preservation in elderly patients with invasive bladder cancer. Int J Radiat Oncol Biol Phys 2014;88:326-331.
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2015
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