Radical Radical ccystectomy in ystectomy in patients over 70 patients over 70

J.SokołowskiJ.Sokołowski, T. Szydełko, P.Kowal,, T. Szydełko, P.Kowal, W.Kołaczyk W.Kołaczyk, , J.Dembowski, W.Dobrucki, R.Zdrojowy, A.Kołodziej, J.Dembowski, W.Dobrucki, R.Zdrojowy, A.Kołodziej,

M.Fiutowski, M.Belda, K.Dudek, T.Niezgoda, J.Lorenz M.Fiutowski, M.Belda, K.Dudek, T.Niezgoda, J.Lorenz

Chair andChair and Clinic of Urology Wroclaw Medical UniversityClinic of Urology Wroclaw Medical UniversityJerzy Lorenz, Prof.,MD, PhD, Head of ClinicJerzy Lorenz, Prof.,MD, PhD, Head of ClinicWSS Urological Department in WrocławWSS Urological Department in Wrocław

Jerzy Sokołowski,MD, PhD, Head of hospital departmentJerzy Sokołowski,MD, PhD, Head of hospital departmentUrological Department in LegnicaUrological Department in Legnica

Wojciech Kołaczyk, MD, PhD, Head of hospital departmentWojciech Kołaczyk, MD, PhD, Head of hospital department

Radical cystectomy is Radical cystectomy is recognized as the golden recognized as the golden

standard in the treatment of standard in the treatment of ininvasivevasive bladder tumour bladder tumourss..

Cystectomy is a Cystectomy is a massive and massive and technically hard operation that technically hard operation that bears a high risk of early and bears a high risk of early and postoperative complications. postoperative complications.

Thus the specification of particular Thus the specification of particular indications indications and contraindications and contraindications related to this related to this procedure procedure appears appears

to be tremendously important.to be tremendously important.

The age of the patient is one of The age of the patient is one of the factors that may have an the factors that may have an

influence on the safety of influence on the safety of intervention. intervention.

There are many distempers of There are many distempers of intra-systemic balance in patients intra-systemic balance in patients

over 70. Mainly, over 70. Mainly, they arethey are related to related to ::

cardio-cardio-vascular systemvascular system

rrespiratoryespiratory system system

eendocrinendocrine system system

alimentary system. alimentary system.

The aThe authors were trying to answer uthors were trying to answer the question whether the age of the the question whether the age of the patient who underwent cystectomy patient who underwent cystectomy

because of bladder cancer is a because of bladder cancer is a crucial factor that has an influence crucial factor that has an influence

on the safety of the very on the safety of the very intervention and the number of intervention and the number of postoperative complications.postoperative complications.

The age of 70 was agreed to The age of 70 was agreed to be the bordering measurement be the bordering measurement

taking into accounttaking into account that the that the changes of the functioning of changes of the functioning of cardio-cardio-vascularvascular, respiratory, , respiratory,

endocrine and alimentary endocrine and alimentary systemsystemss are vividly increased at are vividly increased at

this age.this age.

Since 1996 till 2002Since 1996 till 2002 600 radical cystectomies 600 radical cystectomies

because of bladder cancer were because of bladder cancer were carried outcarried out in in : :

Clinic of Urology of Wroclaw Clinic of Urology of Wroclaw Medical University Medical University

WSS Urological Department in WSS Urological Department in WrocławWrocław

Urological Department in Urological Department in Legnica.Legnica.

The results ofThe results of the the treatment of treatment of 127 patients were analysed.127 patients were analysed.

All the interventions were All the interventions were performedperformed with the with the same operative technique.same operative technique.

Patients were divided into two age groups: Patients were divided into two age groups: 70-75 year olds (90 patients - 71%)70-75 year olds (90 patients - 71%) and over and over 75 (37 patients - 29%).75 (37 patients - 29%).

The health condition of 54 patients was The health condition of 54 patients was estimated estimated according to according to the scale of American the scale of American Anaesthesiology Association (ASA).Anaesthesiology Association (ASA).

ASA 1/2ASA 1/2 2 patients2 patients

ASA 2ASA 2 23 patients23 patients

ASA 2/3ASA 2/3 6 patients6 patients

ASA 3ASA 3 18 patients18 patients

ASA 3/4ASA 3/4 4 patients4 patients

ASA 4ASA 4 1 patient1 patient

In 81 (63%) patients an attemptIn 81 (63%) patients an attempt was made to save was made to save the bladder the bladder before before finallyfinally cystectomy cystectomy was was

decided ondecided on..

Methods of treatment before Methods of treatment before cystectomy.cystectomy.

TUR-TUR-BBTT 1x – 33 patients1x – 33 patients

2x – 15 patients2x – 15 patients

3x – 11 patients3x – 11 patients

more thanmore than 3x – 8 3x – 8 patientspatients

MVACMVAC 7 patients7 patients

RTG - therapyRTG - therapy 4 patients4 patients

OEROER

(open (open eelectroresection)lectroresection)

2 patients2 patients

PBRPBR

(partial bladder resection)(partial bladder resection)

1 patient1 patient

Stage of the diseaseStage of the disease

T0T0 1 patient1 patient

T1mT1m 7 patients7 patients

T2aT2a 7 patients7 patients

T2bT2b 15 patients15 patients

T3aT3a 19 patients19 patients

T3bT3b 36 patients36 patients

T4T4 48 patients48 patients

TotalTotal 127 patients127 patients

Methods of urinary diversion. Methods of urinary diversion.

BrickBrickeer r ooperationperation 46 patients46 patients

Ileal neobladderIleal neobladder 27 patients27 patients

Transuretero-ureterostomy Transuretero-ureterostomy + nephrostomy+ nephrostomy

28 patients28 patients

Ureterocutaneostomy Ureterocutaneostomy 18 patients18 patients

Mainz pouch IIMainz pouch II 3 patients3 patients

Bilateral percutaneous Bilateral percutaneous nephrostomynephrostomy

2 patients2 patients

Transuretero-Transuretero-ureterocutaneostomyureterocutaneostomy

3 patients3 patients

ResultsResults

All the patients survived the operationAll the patients survived the operation

The average time of the operation was 4 The average time of the operation was 4 hrs. 50 min.hrs. 50 min.

The loss of the blood during the The loss of the blood during the intervention was, on average 1100 ml intervention was, on average 1100 ml

Intraoperative complicationsIntraoperative complications

Rectum injuryRectum injury 2 patients2 patients

Massive bleedingMassive bleeding 4 patients4 patients

Early complications after Early complications after cystectomy.cystectomy.

eventerationeventeration 10 patients10 patients

bleedingbleeding 2 patients2 patients

ileusileus 1 patient1 patient

peritonitisperitonitis 3 patients3 patients

nnecrosis of ecrosis of uuretero-retero-iintestinal ntestinal aanastomosis nastomosis

1 patient1 patient

pelvic abscesspelvic abscess 1 patient1 patient

lymphorhoealymphorhoea 5 patients5 patients

pneumoniapneumonia 6 patients6 patients

Early complications after Early complications after cystectomy.cystectomy.

tthrombophlebitishrombophlebitis 3 patients3 patients

uurinary rinary ffistula (istula (lleak of eak of aanastomosis)nastomosis)

2 patients2 patients

rrespiratory espiratory ffailureailure 3 patients3 patients

ccardiac ardiac iinfarctnfarct 4 patients4 patients

ppulmonary ulmonary eembolismmbolism 1 patient1 patient

TotalTotal 36 patients ( 28% )36 patients ( 28% )

Early complications after Early complications after cystectomy.cystectomy.

The The first age group first age group 22 patients22 patients

The second age groupThe second age group 14 patients14 patients

Reoperation was required in 18 patientsReoperation was required in 18 patients

8 patients died after the operation8 patients died after the operation( 6,2% )( 6,2% )

Heart infarct Heart infarct 4 patients4 patients

Pulmonary embolism Pulmonary embolism 1 patient1 patient

Pneumonia Pneumonia 3 patients3 patients

Late postoperative complicationsLate postoperative complications20 patients20 patients

The first age group The first age group 13 patients13 patients

The second age group The second age group 7 patients7 patients

Reoperation was required in 14 patientsReoperation was required in 14 patients

Because of cancer Because of cancer advancement 25 (19,6%) advancement 25 (19,6%)

patients died patients died duringduring the first the first 12 12 months of months of the the postoperative postoperative

periodperiod. . 21 21 more more patients patients died died the following year.the following year.

ConclusionsConclusionsThe analysisThe analysis of 127 of 127 casescases of cystectomy of cystectomy

performed in patients over 70, performed in patients over 70, has led us to has led us to the conclusionthe conclusion that that the method remains an the method remains an effective treatmenteffective treatment of of invasive cancer even invasive cancer even though the number of complications in that though the number of complications in that

age group is higher than in younger age group is higher than in younger patients.patients.

ConclusionsConclusions

The risk of complications The risk of complications occurence rises with the age occurence rises with the age

of the patient and is of the patient and is considerably higher in considerably higher in

patients over 75.patients over 75.