Comparison of survival in elderly patients treated with uretero-cutaneostomy or ileal conduit after radical cystectomy

Abstract

Background: In bladder cancer patients with age ≥ 80 years old, there have been controversies in performing uretero-cutaneostomy or ileal conduit as urinary diversion after radical cystectomy. Limited study evaluated overall survival (OS) and cancer-specific survival (CSS) between the two urinary diversions in elderly patients. This study is to compare OS and CSS between uretero-cutaneostomy and ileal conduit after radical cystectomy in bladder cancer patients with age ≥ 80 years old.

Patients and methods: Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Bladder cancer patients diagnosed between 2004 and 2016 with age ≥ 80 years old who underwent radical cystectomy with either UC or IC were selected. After propensity score matching, Cox regression and Kaplan-Meier analysis were used to analyze the survival. We calculated statistical power for survival.

Results: Of 1394 patients who met the inclusion criteria, 1093 underwent ileal conduit and 301 underwent uretero-cutaneostomy. After propensity score matching, 285 patients were included in each group. Multivariable Cox analysis showed urinary diversion was not a risk factor of OS and CSS (HR 1.044, [95% CI 0.867-1.257] and 1.012 [0.748-1.368], respectively). Both OS and CSS were not significantly different, with median survival of ileal conduit and uretero-cutaneostomy were 19 [16-24] months and 19 [15-26] months respectively. Additionally, We found OS had the following risk factors: tumor stage (distant vs regional vs localized, 5.332 [3.610-7.875] vs 1.730 [1.375-2.176] vs 1), node density (>0.2 vs ≤0.2 vs none, 1.410 [1.047-1.898] vs 0.941 [0.658-1.344] vs 1) and age (1.067 [1.032-1.103] for each year). While CSS had the following risk factors: tumor stage (distant vs regional vs localized, 4.035 [2.046-7.959] vs 2.476 [1.651-3.713] vs 1), node density (>0.2 vs ≤0.2 vs none, 2.501 [1.645-3.804] vs 1.062 [0.590-1.914] vs 1) and tumor size (greater than 3 cm vs less than 3 cm, 1.596 [1.057-2.412] vs 1). Our analysis obtained 0.707 power for overall survival.

Conclusion: Urinary diversion by uretero-cutaneostomy or by ileal conduit was not associated with overall and cancer-specific survival. It is reasonable to consider uretero-cutaneostomy as a regular procedure of urinary diversion in elderly bladder cancer patients after radical cystectomy to avoid associate complications.

Keywords: 80 and over; Aged; SEER program; Urinary bladder neoplasms; Urinary diversion.

Fig. 1

Kaplan-Meier curve of overall survival according to urinary diversion after propensity score matching. No significant difference is found between ileal conduit and uretero-cutaneostomy with median survival 19 months (95% CI 16–24) and 19 months (95% CI 15–26) respectively (p = 0.652). Survival is measured in months

Fig. 2

Kaplan-Meier curve of cancer-specific survival according to urinary diversion after propensity score matching. No significant difference is found between ileal conduit and uretero-cutaneostomy (p = 0.936). Survival is measured in months

Fig. 3

Power-effect curve of overall survival (a) and cancer-specific survival (b) with N = 570 and alpha = 0.05. Vertical dotted line indicates postulated hazard ratio of 1.257; Horizontal dotted line indicates the power; N = 570 because 285 patients are in each urinary diversion group