LETTER TO THE EDITOR
Re: Results from three municipal hospitals regarding radical cystectomy on elderly patients
Matthias MayI; Stephanie FuhrerI; Kay-P. BraunI; Sabine Brookman-AmissahI; Willi RichterII; Bernd HoschkeI; Horst VoglerIII; Michael SiegsmundII
IDepartment of Urology, Carl-Thiem Hospital, Cottbus
IIDepartment of Urology, Vivantes-Clinic Am Urban, Berlin
IIIDepartment of Urology, Vivantes-Clinic Friedrichshain, Berlin, Germany
Int Braz J Urol, 33: 764-776, 2007
To the Editor:
The evaluation of radical cystectomy outcomes in the elderly population is an important issue. The authors present their data from three community hospitals and we need to congratulate them for the needed considerable effort. The median age median of this cohort was 77.6 years, with only 22 patients being older than 77 years. Nonetheless, this study supports the fact that older patients can safely undergo radical cystectomy at municipal centers.
Surgical volume of radical cystectomy is an important predictor of risk of complications and overall survival. The focus of the present study is municipal non-university related hospitals, where the overall mean volume was about 12.5 cases per year per hospital. This would be appropriately called an intermediate or even a high volume institution (1), not a low volume institution where the risk of complications is consistently proven to be higher.
An intriguing finding of the present series is that the overall survival equals progression free survival. Bladder cancer patients, especially older patients, would be expected to have competing risks for mortality other than bladder cancer, especially when considering this cohort, which had a mean ASA class of 3. The authors state that virtually all the patients died of bladder cancer. Although the follow-up is perhaps too short to fully evaluate this point, we would still expect a small difference between overall and progression free survival at 5 years. For organ-confined, extra-organ and node positive disease, the difference is about 7%, 15% and 27% (2). We want to stress the point that risk of complication must always be balanced against invasiveness and quality of the oncologic procedure.
Retrospective comparison of outcomes between different institutions is beset with major methodological difficulties. There are often major differences in patient population and selection biases, different definition of outcomes, different approaches in disease management and surgical techniques, to name only a few potential limitations. One must also note that the retrospective comparison of patient groups within institutions is threatened by the same biases. It is also important to note that other patient specific characteristics not commonly recorded such as cognitive status and functional status can also have a direct impact on post-operative morbidity and mortality.
Overall, these data support the feasibility and clinical utility of surgical treatment in the elderly patient. Series like the present one demonstrate that with careful patient selection, in centers with intermediate or higher volume, radical cystectomy appears feasible. Long term oncological results are awaited.
Dr. Vincent Fradet & Dr. Badrinath R. Konety
Departments of Urology and Epidemiology
University of California, San Francisco
San Francisco, CA, USA
E-mail: vfradet@mac.com
- 1. Konety BR, Dhawan V, Allareddy V, Joslyn SA. Impact of hospital and surgeon volume on in-hospital mortality from radical cystectomy: data from the health care utilization project. J Urol. 2005; 173: 1695-700.
- 2. Bochner BH, Kattan MW, Vora KC: Postoperative nomogram predicting risk of recurrence after radical cystectomy for bladder cancer. J Clin Oncol. 2006; 24: 3967-72.
Publication Dates
-
Publication in this collection
26 May 2008 -
Date of issue
Feb 2008
