Radical cystectomy in the elderly

Comparison of clinical outcomes between younger and older patients

Abstract

BACKGROUND

The authors report their experience with radical cystectomy for transitional cell carcinoma (TCC) of the bladder comparing clinical outcomes, including complication rates, among older patients versus younger patients in a high-volume center specializing in the treatment of patients with advanced carcinoma of the urinary bladder.

METHODS

A retrospective review was undertaken of 1054 patients who underwent radical cystectomy for bladder TCC from 1971 through 1997. Four age groups were compared; < 60 years at the time of cystectomy (n = 309 patients), age 60–69 years (n = 381 patients), age 70–79 years (n = 314 patients), and age ≥ 80 years (n = 50 patients).

RESULTS

The median length of hospital stay in patients ages < 60 years, 60–69 years, 70–79 years, and ≥ 80 years was 10 days, 10 days, 11 days, and 11 days, respectively (P < 0.001). The corresponding rates of overall early complications were 24%, 25%, 37%, and 30%, respectively (P = 0.002); whereas the corresponding late complication rates were 36%, 30%, 22%, and 14%, respectively (P < 0.001). The rate of early diversion-related complications did not differ significantly (11%, 8%, 12%, and 6%, respectively; P = 0.14). The operative mortality rates were 1%, 3%, 4%, and 0%, respectively (P = 0.14). There was no difference with respect to early complications, early diversion-related complications, late complications, or operative mortality comparing patients age > 70 years who underwent ileal conduit versus orthotopic urinary diversion (P = 0.20, P = 0.61, P = 0.53, and P = 0.78, respectively).

CONCLUSIONS

Elderly patients who underwent cystectomy for TCC had similar mortality and early diversion-related complication rates. Carefully selected elderly patients safely can be offered an orthotopic urinary diversion. Chronological age, per se, is not a contraindication for radical cystectomy in the setting of invasive bladder carcinoma. Cancer 2005. © 2005 American Cancer Society.

With improvements in medical technology and health care, the population of the United States has aged progressively as the average life span has increased, and this trend is expected to continue well into the new century.1, 2 Transitional cell carcinoma (TCC) is a disease predominantly of the elderly with a peak incidence in the seventh decade of life.3 The issue of managing TCC in the elderly, therefore, is of increasing importance.

Among patients with TCC, 20–40% will present with or will develop muscle-invasive disease. In the United States, the standard of care for muscle-invasive TCC is a radical cystectomy with urinary diversion.4 In the elderly, however, some have advocated the use of less aggressive forms of treatment.5 Nevertheless, a number of centers, including our institution, have shown that radical cystectomy with urinary diversion can be performed safely in properly selected elderly patients.6–25 Only two of those series included elderly patients who had undergone urinary diversion with a continent cutaneous reservoir,18, 21 whereas the report by Figueroa et al. is the only one that included patients who underwent diversion with an orthotopic neobladder.21 The latter report included all patients who underwent cystectomy at the Norris Comprehensive Cancer Center up to December, 1996. The current report seeks to update this experience in a more rigorously defined population and to compare the outcomes between younger and older patients. In particular, we sought to explore the influence of age on complication rates (especially with respect to orthotopic vs. ileal conduit urinary diversions), operative mortality, and length of hospital stay. It is emphasized that our results reflect the experience of a large-volume center that specializes in advanced bladder carcinoma.

MATERIALS AND METHODS

An Institutional Review Board-approved, comprehensive data base of all patients who underwent cystectomy at our institution from August, 1971 to December, 1997 was reviewed retrospectively. In total, 1471 patients with records available were identified. Patients were excluded from the analysis for the following reasons: cystectomy for a nonbladder primary malignancy (n = 72 patients); non-TCC as primary bladder histology (n = 107 patients); salvage cystectomy after failure of definitive radiation therapy, defined as ≥ 5000 rads (n = 126 patients); deemed inoperable at the time of cystectomy (n = 23 patients); distant metastases demonstrated at the time of cystectomy (n = 46 patients); and evidence after resection of macroscopic residual disease at the time of cystectomy (n = 43 patients). The remaining 1054 patients all underwent radical cystectomy with curative intent for primary TCC of the bladder. They included 843 men and 211 women with a median age of 66 years (age range, 22–93 years). The overall clinical outcomes of this strictly defined cohort of patients have been reported previously.26 For this report, patients were grouped into 4 different age groups according to their age at the time of cystectomy: age < 60 years (n = 309 patients), age 60–69 years (n = 381 patients), age 70–79 years (n = 314 patients), and age ≥ 80 years (n = 50 patients).

All patients who were considered for radical cystectomy underwent a rigorous preoperative physical examination and screening to ensure adequate cardiac and physical performance status. Routine preoperative studies included a comprehensive metabolic panel, including liver function studies, complete blood count, chest X-ray, electrocardiogram, and abdominal and pelvic computerized tomography scans. More specific preoperative screening and medical clearance was performed on a selected basis. It should be emphasized that only patients who were deemed appropriate surgical candidates by the operating surgeon were included in this data base. Information on patients who were evaluated but who never underwent radical cystectomy is not available.

Over the last 30 years, the approach to neoadjuvant therapy for invasive TCC has changed. For example, from 1971 to 1978, 97 patients from this cohort received a short course of high-dose neoadjuvant radiotherapy (1600 rads) over 4 days immediately before cystectomy. Subsequent analysis of the results from these patients has shown no benefit to this approach, and neoadjuvant radiotherapy has not been applied routinely since 1979.27 Similarly, only 48 patients from this cohort received neoadjuvant chemotherapy, although the recent randomized, controlled study from the Southwest Oncology Group suggesting a benefit to neoadjuvant cisplatin, methotrexate, vinblastine, and doxorubicin therapy may alter this in the future for selected patients.28

Radical cystectomy with en bloc bilateral pelvic lymphadenectomy was performed in a standard fashion as described previously.29 The only change in operative technique in the elderly was a more ginger lymph node dissection in patients who had significant arteriosclerosis of their iliac arteries. All patients underwent urinary diversion in a standard fashion. All patients, except those with a prior history of gastric surgery, underwent routine placement of an open gastrostomy tube at the time of cystectomy. This was left in place until the complete return of bowel function, typically on postoperative Days 5–7.

Postoperatively, patients routinely were admitted to the intensive care unit for 12–48 hours. Patients age > 65 years routinely received prophylaxis with digoxin, and all patients received oral warfarin therapy for prophylaxis against thromboembolic complications. Digoxin was administered at 0.125 mg per day while in the hospital, and warfarin was started on the day of surgery with the objective of maintaining the protime between 16 and 20 seconds. The safety and tolerability of this approach have been verified previously.12, 21, 30, 31 Patients with a continent urinary diversion (cutaneous or orthotopic) were admitted overnight to the hospital 3 weeks after surgery for removal of their reservoir catheter and ureteral stents, followed by removal of the Penrose drain the next morning.

Patients were followed up at 4-month intervals for the first year, at 6-month intervals for the second year, and annually thereafter. Routine follow-up studies included a thorough history and physical examination and serum studies, including electrolytes, creatinine, and liver function tests. Chest X-rays and radiographic evaluations of the reservoir and upper tracts through intravenous pyelography, ultrasound, and/or pouch/cystogram, as appropriate, were done at 4 months after cystectomy and yearly thereafter. Bone scans or computerized tomography scans were obtained as indicated clinically. The median follow-up for the entire group was 10.2 years. The maximum follow-up was 27 years, and 91% of patients had at least 3 years of follow-up.

The clinical outcomes analyzed included operative mortality (defined as any death within 30 days after cystectomy or prior to discharge after surgery), early complications (defined as occurring within 90 days of cystectomy or prior to discharge from the hospital), and late complications (defined as occurring > 90 days after cystectomy). Early complications were broken down further by whether or not they were diversion-related. Outcomes with respect to overall and recurrence-free survival in older patients versus younger patients is the subject of a separate analysis.

Contingency tables and Pearson chi-square tests were used to evaluate the association between pairs categorical (demographic and clinical) variables. Pairwise comparisons were performed only if the overall, global test was significant at the 0.05 level. The Kruskal–Wallis test was used to examine the differences of the length of hospital stay after radical cystectomy in different age groups. All P values reported are two-sided.

RESULTS

The distribution according to length of follow-up, gender, and diversion type by age group is outlined in Table 1. Note that elderly patients were more likely to undergo an ileal conduit diversion and were less likely to undergo a continent cutaneous reservoir diversion (P = 0.013). There was a trend toward a lower proportion of patients age > 80 years and a slightly higher proportion of patients age 70–79 years undergoing orthotopic diversion compared with younger patients. However, these distributions were not significant (pair-wise comparison of ileal conduit vs. orthotopic diversion, P = 0.39; orthotopic vs. other continent diversion, P = 0.067).

Table 1. Demographic Information and Distribution of Diversion Type Stratified by Patient Agea

Age group	Median FU (mos)	Male:female ratio	Diversion type: No. of patients (%)
			Ileal conduit	Orthotopic	Continent (other)
FU: follow-up. a Patients were divided into those who underwent an ileal conduit form of diversion, orthotopic neobladder, or another nonorthotopic continent form of urinary diversion (e.g., continent cutaneous reservoir or ureterosigmoidostomy). Chi-square analysis for the group as a whole demonstrated significant differences in the frequency distribution of diversion type by age group (P < 0.001). Pair-wise comparisons after establishing an overall difference are as follows: for ileal conduit versus orthotopic diversion, P = 0.39; for ileal conduit versus other continent diversion, P = 0.013; and for orthotopic versus other continent diversion, P = 0.067.
< 60 yrs	144	254:56	74 (24.0)	123 (40.0)	112 (36.0)
60–69 yrs.	138	305:77	91 (24.0)	151 (40.0)	139 (36.0)
70–79 yrs	116	249:63	83 (26.0)	150 (48.0)	81 (26.0)
≥ 80 yrs	157	35:15	23 (46.0)	18 (36.0)	9 (18.0)

Clinical outcomes are outlined in Table 2. Note that there was no significant difference in operative mortality between the 4 age groups (P = 0.14). The rate of early complications was higher in the older age groups; however, the rates of diversion-related early complications in the 4 age groups (ages < 60 years, 60–69 years, 70–79 years, and ≥ 80 years) were 11%, 8%, 12%, and 6%, respectively (P = 0.14). The difference in median length of stay was significantly different (P < 0.001), but the absolute difference was only 1 day. The distribution of complications according to organ system for each age group is outlined in Table 3. Table 4 outlines the clinical results when the analysis was restricted to patients age > 70 years and compares outcomes cross-classified by the type of urinary diversion. There was no significant difference in the rates of early complications (overall or diversion-related), late complications, or operative mortality between elderly patients who received an ileal conduit versus an orthotopic urinary diversion (P = 0.20, P = 0.61, P = 0.53, and P = 0.21, respectively).

Table 2. Clinical Outcomes by Age Group

Age group (no. of patients)	Median LOS in days (quartile range)	Outcome: No. of patients (%)
		Early complications	Late complications	Operative mortality
LOS: length of stay. a P value is based on Kruskal–Wallis test. b P value is based on chi-square test.
< 60 yrs (309)	10 (8–11)	75 (24.0)	111 (36.0)	4 (1.0)
60–69 yrs (381)	10 (8–12)	95 (25.0)	116 (30.0)	11 (3.0)
70–79 yrs (314)	11 (9–13)	115 (37.0)	69 (22.0)	12 (4.0)
≥ 80 yrs (50)	11 (10–14)	15 (30.0)	7 (14.0)	0 (0.0)
P value	< 0.001a	0.002b	< 0.001b	0.14b

Table 3. Complications by Early versus Late and Major versus Minor for Each Age Groupa

System or type	Age group: No. of patients (%)
	< 60 yrs	60–69 yrs	70–79 yrs	≥ 80 yrs
IPP: inflatable penile prosthesis, AUS: artificial urinary sphincter. a Major complications were any complication that required either a minimally invasive or open surgical procedure, whereas minor complications required no specific therapy or only medical therapy. Percentages are of the total number of patients in each age group. b Examples of complications include cardiovascular (myocardial infarction, bradycardia, atrial flutter, congestive heart failure), diversion-related (urinary leak, afferent/efferent limb malfunction or stenosis, stomal stenosis, urinary fistula, ureteroenteric anastomotic stricture), gastrointestinal (small bowel obstruction, gastrointestinal bleed, enteric fistula, hepatic failure, diarrhea), infectious disease (sepsis, pneumonia, pyelonephritis, abscess, urinary tract infection, clostridium colitis), lymphatic (lymphedema, lymphocele), neurologic (cerebrovascular accident, seizure, nerve palsy, psychosis), pulmonary (respiratory failure, pneumothorax, asthma exacerbation), renal (calculous disease, hyperchloremic metabolic acidosis, renal failure), vascular/thrombosis (deep venous thrombosis, pulmonary embolus, mesenteric thrombosis), wound/incision/hernia (superficial wound infection, incisional hernia, fascial dehiscence, parastomal hernia) or other (gout, drain migration, hydrocele).
Cardiovascularb
Early
Minor	2 (1.0)	6 (2.0)	14 (4.0)	1 (2.0)
Major	0 (0.0)	0 (0.0)	1 (0.3)	1 (2.0)
Late
Minor	2 (1.0)	2 (1.0)	3 (1.0)	0 (0.0)
Major	0 (0.0)	2 (1.0)	0 (0.0)	0 (0.0)
Dehydration
Early
Minor	5 (2.0)	17 (4.0)	20 (6.0)	2 (4.0)
Major	0 (0.0)	1 (0.3)	0 (0.0)	0 (0.0)
Late
Minor	4 (1.0)	4 (1.0)	2 (1.0)	0 (0.0)
Major	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
IPP/AUS malfunction
Early
Minor	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Major	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Late
Minor	0 (0.0)	1 (0.3)	0 (0.0)	0 (0.0)
Major	20 (6.0)	8 (2.0)	3 (1.0)	0 (0.0)
Diversion relatedb
Early
Minor	29 (9.0)	22 (6.0)	22 (7.0)	5 (10.0)
Major	31 (10.0)	27 (7.0)	29 (9.0)	4 (8.0)
Late
Minor	4 (1.0)	9 (2.0)	16 (5.0)	1 (2.0)
Major	98 (32.0)	110 (29.0)	37 (12.0)	1 (2.0)
Gastrointestinalb
Early
Minor	3 (1.0)	7 (2.0)	4 (1.0)	0 (0.0)
Major	3 (1.0)	4 (1.0)	10 (3.0)	4 (8.0)
Late
Minor	6 (2.0)	4 (1.0)	3 (1.0)	1 (2.0)
Major	27 (9.0)	17 (4.0)	20 (6.0)	0 (0.0)
Hemorrhage/bleeding
Early
Minor	0 (0.0)	2 (1.0)	1 (0.3)	1 (2.0)
Major	3 (1.0)	2 (1.0)	5 (2.0)	0 (0.0)
Late
Minor	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Major	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Infectious diseaseb
Early
Minor	6 (2.0)	16 (4.0)	23 (7.0)	2 (4.0)
Major	1 (0.3)	1 (0.3)	1 (0.3)	0 (0.0)
Late
Minor	25 (8.0)	15 (4.0)	28 (9.0)	4 (8.0)
Major	9 (3.0)	9 (2.0)	4 (1.0)	0 (0.0)
Lymphaticb
Early
Minor	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Major	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Late
Minor	8 (3.0)	18 (5.0)	4 (1.0)	0 (0.0)
Major	2 (1.0)	1 (0.3)	1 (0.3)	0 (0.0)
Neurologicb
Early
Minor	2 (1.0)	4 (1.0)	7 (2.0)	1 (2.0)
Major	0 (0.0)	1 (0.3)	0 (0.0)	0 (0.0)
Late
Minor	1 (0.3)	1 (0.3)	3 (1.0)	0 (0.0)
Major	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Pulmonaryb
Early
Minor	0 (0.0)	1 (0.3)	2 (1.0)	0 (0.0)
Major	1 (0.3)	3 (1.0)	4 (1.0)	1 (2.0)
Late
Minor	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Major	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Renalb
Early
Minor	4 (1.0)	5 (1.0)	7 (2.0)	1 (2.0)
Major	2 (1.0)	3 (1.0)	3 (1.0)	0 (0.0)
Late
Minor	5 (2.0)	11 (3.0)	5 (2.0)	0 (0.0)
Major	76 (20.0)	46 (12.0)	23 (7.0)	0 (0.0)
Vascular/thrombosisb
Early
Minor	4 (1.0)	18 (5.0)	13 (4.0)	2 (4.0)
Major	1 (0.3)	2 (1.0)	3 (1.0)	1 (2.0)
Late
Minor	3 (1.0)	7 (2.0)	1 (0.3)	0 (0.0)
Major	0 (0.0)	0 (0.0)	2 (1.0)	0 (0.0)
Wound/incision/herniab
Early
Minor	6 (2.0)	7 (2.0)	4 (1.0)	1 (2.0)
Major	1 (0.3)	2 (1.0)	1 (0.3)	0 (0.0)
Late
Minor	6 (2.0)	17 (4.0)	9 (3.0)	0 (0.0)
Major	40 (13.0)	54 (14.0)	21 (7.0)	1 (2.0)
Otherb
Early
Minor	1 (0.3)	1 (0.3)	1 (0.3)	1 (2.0)
Major	2 (1.0)	1 (0.3)	0 (0.0)	0 (0.0)
Late
Minor	3 (1.0)	5 (1.0)	2 (1.0)	1 (2.0)
Major	8 (3.0)	3 (1.0)	4 (1.0)	1 (2.0)

Table 4. Clinical Outcomes of Patients Age ≥ 70 Years at the Time of Radical Cystectomy Grouped by Whether the Patient Received an Orthotopic Neobladder, an Ileal Conduit, or Another (Nonorthotopic) Form of Continent Diversiona

Diversion type (no. of patients)	No. of patients (%)
	Early complications	Early diversion-related complications	Late complications	Operative mortality
a Other (nonorthotopic) forms of continent diversion included, e.g., continent cutaneous reservoir or ureterosigmoidostomy. b Pairwise comparison demonstrated no significant difference between ileal conduits and orthotopic neobladders (P = 0.53).
Ileal conduit (106)	37 (35.0)	11 (10.0)	17 (16.0)b	3 (3.0)
Orthotopic neobladder (168)	54 (32.0)	18 (11.0)	32 (19.0)b	5 (3.0)
Continent-other (90)	39 (43.0)	13 (14.0)	27 (30.0)	4 (4.0)
P value	0.20	0.61	0.04	0.78

DISCUSSION

The current results support the concept that radical cystectomy and orthotopic urinary diversion can be offered safely to carefully selected elderly patients. Although there was a difference in overall early complications between older patients versus younger patients, we found no difference in either operative mortality rates or early diversion-related complications. When we limited the analysis to patients age > 70 years, there was no difference in early complications, early diversion-related complications, late complications, or operative mortality in patients who underwent ileal conduit compared with patients who underwent orthotopic urinary diversion.

Due to the poor results with radiation, a number of authors have investigated the use of cystectomy in the elderly (see Table 5).6–25 In general, these investigations have shown that radical cystectomy can be performed safely in properly selected elderly patients. Although the mortality rates across these series have varied widely from 0% to 18%, among the 819 unique patients in these series, the overall mortality rate was 4%. In the current series, the mortality rate was between 0% and 4% for all age groups, consistent with other reports in the literature.

Table 5. Reports on Radical Cystectomy in Elderly Patients

Report	No. of patients	Definition of elderly (yrs)	Mortality rate (%)	Difference vs. younger patients	Early/late complication rate (%)	Difference vs. younger patients
a The rate was not discernable from this report, but statistical analysis indicated no differences. b Dementia. c Reoperation.
Kursh et al., 19776	25	70–80	0.0	—	40.0	—
Zingg et al., 19807	24	≥ 70	18.0	—	54.0/—	—
Zincke., 19828	19	≥ 80	5.3	—	47.0/	—
Thomas and Riddle, 19829	41	≥ 65	12.0	Yes	—	Noa
Drago and Rohner, 198310	28	≥ 70	0.0	—	—	—
Tachibana et al., 198311	9	≥ 80	0.0	No	67.0b	Yes
Skinner et al., 198412	77	≥ 65	3.9	—	34.0/—	—
Ogawa et al., 198513	9	≥ 80	0.0	—	33.0
Wood et al., 188714	38	≥ 70	5.3	No	34.0	No
Orihuela and Cubelli, 198715	7	≥ 80	14.0	—	—	—
Jacqmin et al., 198916	39	> 70	2.5	—	7.7c	—
Leibovitch et al., 199317	42	≥ 70	9.5	No	—	Noa
Navon et al., 199518	21	≥ 75	9.5	—	28.0/48.0	—
Koch and Smith, 199619	47	≥ 70	—	Noa	—	Noa
Stroumbakis et al., 199720	44	≥ 80	4.5	—	51.0	—
Figueroa et al., 199821	404	≥ 70	2.8	No	32.0/12.4	No
Rosario et al., 200022	33	≥ 70	0.0	No	—	—
Lance et al., 200123	36	> 80	0.0	—	62.0	—
Chang et al., 200124	44	≥ 75	0.0	—	27.0/—	—
Game et al., 200125	25	≥ 75	4.0	—	64.0/24.0	—

A number of reports have compared the results of cystectomy in elderly patients versus younger patients (see Table 5). One of the earliest was from Thomas and Riddle, who noted a 12.0% operative mortality rate among patients age > 65 years compared with 3.4% among younger patients.9 With further refinements in surgical and anesthetic techniques, all subsequent series, including the current series, found no difference in operative mortality between elderly patients versus younger patients.11, 14, 17, 19, 21, 22

Complication rates have varied widely between cystectomy series in elderly patients, from 7.7% to as high as 67% (see Table 5).6–25 Comparisons are very difficult, because the series all differ considerably in how a complication was defined, whether or not late complications were included, and how long the patients were followed. Nevertheless, the complication rates in the current series fit well within the range of early complication rates (24–35%) and late complication rates (16–39%) reported by other series. It is noteworthy that several previous series reported no significant difference in complication rates between younger and older patients (see Table 4).9, 14, 17, 19, 21 In 4 of those 5 series, the number of elderly patients was < 50, making the statistical power of the studies low.9, 14, 17, 19 Furthermore, none of those four studies broke down complication rates into early and late, as was done in the current series, and only the study by Wood et al. reported the actual complication rate.

The most comparable study to the current series is the earlier report by Figueroa et al., also from the University of Southern California.21 Both that series and the current series divided complications into early and late, and both divided early complications into diversion-related and nondiversion-related. Both groups reported no difference in early diversion-related complications. In the current analysis, we also found no significant differences in early complications (either overall or diversion-related), late complications, or operative mortality comparing elderly patients age > 70 years who underwent an ileal conduit diversion versus an orthotopic urinary diversion. This suggests that, in carefully selected elderly patients, radical cystectomy and orthotopic urinary diversion are feasible and safe.

These results are consistent with a report by Malavaud et al., who found neither age nor diversion type was an independent predictor of complications after cystectomy.32 In that study, the only independent predictor of complications after cystectomy was the patient's American Society of Anesthesiologists (ASA) score.33 Figueroa et al. reported an early complication rate of 32% among patients age > 70 years versus a “comparable” rate of 25% among patients age < 70 years. The late complication rate was 12.4% among patients age ≥ 70 years versus 22.8% among patients age < 70 years. In both cases, no P values were provided, but it was implied that these differences were not significant. The current series showed a significantly higher early complication rate and a lower late complication rate among elderly patients, both consistent with the trend noted in the earlier report. A higher rate of earlier complications probably is related to the higher rate of comorbidities in the elderly. This has been demonstrated in the general surgery literature, in which reports have shown higher complication rates in elderly patients, but these differences disappeared when a patient's comorbidities were taken into account.32, 34–36 Results from the multivariate analysis by Malavaud et al., as noted above, also support the view that complication rates are driven more by comorbidity than by age.32 Unfortunately, direct measures of patient's comorbidity, such as the ASA class or the Charleston comorbidity index, currently are not available for our cohort of patients. In the current study and in the study by Figueroa et al., the late complication rate in the elderly was lower. Intuitively, it may be hypothesized that this is due to the lower overall survival in the elderly population and, thus, shorter follow-up and less opportunity to develop a late complication. However, actuarial survival curves comparing late complications grouped by age (data not shown) do not support this hypothesis. Alternatively, perhaps the tendency to subject elderly patients to more intensive preoperative medical screening decreases the risk of late complications. The exact reason for this observation remains unknown.

The major difference between the report by Figueroa et al. and the current report is that the earlier report included all patients who underwent cystectomy at the University of Southern California from 1971 to 1996.21 No patients were excluded. The current series had numerous exclusions in an effort to restrict the study cohort to patients who underwent primary cystectomy for invasive TCC of the bladder with the intent to cure, as outlined above (see Materials and Methods). This was done to keep the cohort as uniform as is possible in such a retrospective analysis. Therefore, although the current series included patients who underwent surgery between 1971 and 1997, the number of elderly patients age ≥ 70 years was less than the earlier report (363 patients vs. 404 patients). The current series also broke down the patients into 4 age groups, whereas the report by Fiqueroa et al. predominantly compared patients age > 70 years with patients age < 70 years. Furthermore, the analysis of the current study was extended to include complication rates by different diversion types.

In concussion, elderly patients undergoing cystectomy for TCC have equivalent mortality and early diversion-related complication rates. It is safe to offer carefully selected elderly patients an orthotopic urinary diversion. Chronological age, per se, is not a contraindication for radical cystectomy in the setting of invasive bladder carcinoma.