Comparative Analysis of Elderly Patients Undergoing Radical Cystectomy With Ureterocutaneostomy or Ileal Conduit With a Special Focus on Bowl Complications Requiring Surgical Revision

Abstract

ObjectivesIleal conduits (ICs) carry an additional perioperative complication risk due to the bowel procedure. This analysis compares surgical outcomes in patients ≥75 years of age with ureterocutaneostomy (UCN) and IC after cystectomy (Cx).MethodsData of 527 patients included in a retrospective cystectomy database of two high volume centers (2008–2020) were queried to identify elderly patients (≥75 years) who underwent Cx either with IC or UCN. Patient characteristics of all patients [age, BMI, Charlson Comorbidity Index (CCI)], perioperative parameters (operation time, blood loss, transfusions, tumor stage), and postoperative complications (clavien >IIIA, intensive care unit (ICU) stay) were compared. As special focus, bowel complications requiring surgical revision (rBCs) were analyzed. In patients with IC, the rate of ureteral implantation stenosis (USt) was recorded. As a population of special interest, patients ≥80 years of age were analyzed separately. Categorical data were compared using Fisher exact test, and continuous data were compared using Mann–Whitney U test.ResultsA total of 163 patients ≥75 years of age (125 IC, 38 UCN) were identified. Patients with UCN were older and presented with a higher CCI, though differences were not statistically different. Surgery with palliative intent was more frequent in patients with UCN (37 vs. 10%). Operation time in UCN was significantly shorter (233 vs. 305 min, p = 0.02), while blood loss and transfusion rate were comparable. Overall complication rate (Clavien-Dindo grade IIIA–IVB) was comparable (UCN 34% vs. IC 37%). However, rBC was a rare complication in UCN (3/38) as compared to patients with IC (15/125). Frequency of postoperative ICU stay (UCN 16% vs. IC 16%) and 90-day mortality did not differ (UCN 3/38 patients, IC 5/125 patients). Regarding long-term follow-up, USt requiring revision or permanent stenting was seen in 18/125 (14%) patients with IC. In patients >80 years of age, results were comparable to the main cohort. Low event rate regarding complications and bias inherent of a retrospective analysis (selection bias, unequal distribution in case numbers) precludes detection of statistical differences regarding patients' characteristics and overall complication rate.ConclusionUCN is an alternative to IC in elderly and/or frail patients. Severe bowel complications are numerically less frequent and operation time is minimized.

Age represents the main driver of surgical decision making in patients candidate to radical cystectomy

“…They, moreover, experienced more frequently intraoperative transfusions (25% vs. 20%, p = 0.04), postoperative transfusions (28% vs. 22%, p = 0.03), and intraoperative complications (8% vs. 4%, p = 0.04). These observations were in agreement, in terms of transfusions rates, with several previous reports considering octogenarians UBC patients (26%−38%) 15,31,32 . Unfortunately, no direct comparison with the literature could be done in terms of intraoperative complications since available studies on elderly did not provide such data.…”

“…Furthermore, age ≥80 alone portended for UCS as UD of choice with almost fourfold higher odds relative to younger patients. UCS demonstrated to be a preferable UD in elderly in several series, based on lower operative time and complication rates 12,13,15 . Notably, the majority of the patients in these series were submitted to RC with non‐curable intent (40% of extravesical disease/N+UBC in the study of Mally et al and ≥50% in the study of Deliveliotis et al) 13,15 .…”

“…These observations were in agreement, in terms of transfusions rates, with several previous reports considering octogenarians UBC patients (26%−38%). 15,31,32 Unfortunately, no direct comparison with the literature could be done in terms of intraoperative complications since available studies on elderly did not provide such data. Of note, the current study relied on the recently published iAE criteria to standardize the assessment, reporting, and grading of intraoperative complications (i.e., ICARUS) to improve counseling of elderly patients candidate to RC.…”

“…UCS demonstrated to be a preferable UD in elderly in several series, based on lower operative time and complication rates 12,13,15 . Notably, the majority of the patients in these series were submitted to RC with non‐curable intent (40% of extravesical disease/N+UBC in the study of Mally et al and ≥50% in the study of Deliveliotis et al) 13,15 . In elderly patients with limited risk factors for surgical morbidity (i.e., anticoagulant therapy, previous abdominal surgery) and encouraging life expectancy (for muscle invasive UBC usually consisting of ≥2 years), 26,30 UD with bowel manipulation may still be chosen.…”

“…The ultimate surgical strategy for elderly UBC patients has not been tailored yet and is still subject of debate. Specifically, data discourage to submit elderly patients to urinary diversions (UD) requiring bowel manipulation, [12][13][14][15] even if age alone does not represent a criterion of contraindication. Moreover, age is associated with significantly lower adherence to recommendations relative to lymph node dissection (LND), 16,17 despite the absence of data endorsing the omission of LND above a specific age threshold.…”