Muscle-invasive bladder cancer (MIBC) is a disease of the elderly with a median diagnosis at age 73 years. Treating octogenarians, those aged 80-89, with MIBC is of increasing relevance as both life expectancy and healthy life expectancy (the number of years of life lived free of disease or disability) increase globally. As over 80,000 patients are diagnosed with bladder cancer per year in the United States, of whom approximately a quarter will have muscle-invasive disease, we will likely increasingly see patients over 80 years old diagnosed with MIBC.

Curative treatments for MIBC include radical cystectomy (RC), with or without neoadjuvant chemotherapy, and trimodal therapy, which includes maximal transurethral resection, chemotherapy, and radiotherapy. Unfortunately, many elderly patients with MIBC do not receive any curative treatments for a disease with a high risk of metastasis and mortality.¹ Treating MIBC in octogenarians involves thoughtful consideration of patient comorbidities, functional status, and treatment risks.

Although octogenarians with MIBC are significantly less likely to be managed with RC compared to younger patients,¹ well-selected octogenarians benefit from surgery. A large population-based study using the National Cancer Database observed that elderly patients with MIBC treated with RC had the longest survival compared to chemoradiation and nonstandard treatment.¹ The relative underutilization of RC in octogenarians may stem from hesitancy to pursue a major surgery with a high risk of complications in patients who tend to have more comorbidities and a higher prevalence of frailty.²

However, in experienced hands, octogenarians can expect favorable perioperative outcomes with RC. In a cohort of 117 octogenarians who had RC, the risk of postoperative complications was not significantly different compared to 1,025 younger patients.² Compared to younger patients, octogenarians were more likely to be admitted to the intensive care unit postoperatively and had a slightly longer hospital stay, but there were no differences in hospital readmissions. A NSQIP (National Surgical Quality Improvement Program) database study found that octogenarians having RC had a similar risk of complications compared to septuagenarians, but a longer hospital stay and longer operative time.³

Still, octogenarians have a higher risk of perioperative mortality compared to younger patients. An institutional cohort study reported a 90-day mortality of 6.8% in octogenarians compared to 2.2% in younger patients (P = .01).² A population-based database study using the SEER (Surveillance, Epidemiology, and End Results) registry observed a 9.2% 90-day mortality rate in octogenarians, which was 5-fold higher compared to all other RC patients (OR 5.02, P < .001).⁴ The increased perioperative mortality risk for octogenarians must be emphasized during treatment counseling, and particularly vulnerable patients should be cautioned.

ERAS (Enhanced Recovery after Surgery) protocols have been popularized as a means of reducing perioperative morbidity with RC. These protocols generally include expanded use of minimally invasive surgery, restricted intraoperative fluid use, earlier oral feeding, absence of a mechanical bowel preparation, earlier ambulation, and use of alvimopan. Among 71 octogenarian patients treated during an era that included multiple ERAS elements, our group reported that the median time to first bowel movement was 6 d (IQR 4-7), median time to hospital discharge was 9 d (IQR 7-12), and 66% of patients were discharged to home.⁵ Twenty-two percent of patients were readmitted within 90 d. A population-based study of octogenarians having RC reported that patients who had a robotic-assisted RC were discharged earlier, were more likely to be discharged home rather than a nursing facility, and had a significantly lower perioperative mortality compared to open RC.⁶ Thus, contemporary perioperative pathways and advancements in surgical technique may allow octogenarians to better tolerate RC.

Importantly, increasing age has been associated with more advanced disease, a higher risk of recurrence after RC, and decreased cancer-specific survival.⁷ Therefore, octogenarians who have RC may require additional cancer treatments, including perioperative chemotherapy or adjuvant nivolumab. In fact, a large National Cancer Database study reported that octogenarians with MIBC treated with RC and perioperative chemotherapy had the longest survival compared to RC alone or trimodal therapy.⁸ While a minority of octogenarians are typically cisplatin eligible, multimodal treatment plans should be considered.

Selecting a treatment for MIBC in the octogenarian patient can be a complex decision. When considering treatment plans, urologists should account for physiological age, performance status, comorbid conditions, life expectancy, and patient treatment goals. Age-related declines in overall health and functional status contribute to a diminishing physiological reserve that can impact treatment tolerability and risk of complications. As octogenarians are at increased risk for failure to rescue (death following a complication) after RC compared to younger patients, early detection and treatment of postoperative complications are particularly important.⁹ A geriatric assessment may help inform treatment-related decisions for the octogenarian patient with MIBC.¹⁰

When octogenarians are well selected, RC can have comparable perioperative outcomes to younger patients, although the increased risk of mortality must be taken into consideration. If an octogenarian has elected to have RC, surgery should be done in a high-volume center with an experienced multidisciplinary team, including anesthesia, geriatrics, nutrition, nursing, and physical therapy, to optimize perioperative outcomes.