Research Article|Articles in Press

The short- and long-term effect of radical cystectomy in frail patients with bladder cancer

Published:March 09, 2023DOI:



      Studies about perioperative complications and all-cause mortality in frail patients requiring radical cystectomy (RC) are scarce. We aimed to assess the short- and long-term effect of RC in frail patients with bladder cancer.

      Patients and Methods

      We performed a retrospective, cohort study including patients who underwent open RC due to bladder cancer from November 2013 to June 2022. Patients were considered frail when they fulfilled one of the following criteria: i) age ≥ 75 years; ii) Charlson Comorbidity Index ≥ 9; iii) American Society of Anesthesiologists classification ≥ 4; or iv) Clinical Frailty Scale score ≥ 5. We evaluated all-cause mortality and complications in frail versus non-frail patients. The effect of urinary diversion with ileal conduit versus ureterocutaneostomy in frail patients was also assessed via a cox regression analysis.


      Overall, 184 individuals underwent RC (95 frail and 89 non-frail). A total of 130 patients (80%) presented at least one perioperative complication. This proportion was even higher among frail patients (86%). Similarly, severe perioperative complications were more common in frail patients based on the Clavien-Dindo classification (p=0.044). Regarding disease progression and long-term complications, no statistically significant differences were observed between frail and non-frail patients. The survival analysis with Kaplan-Meier curves demonstrated that the risk of death was increased in frail patients (log-rank test=0.027). Based on the multivariate Cox regression analysis adjusting for major risk factors, urinary diversion with ureterocutaneostomy was significantly associated with increased mortality in frail patients compared to ileal conduit (Hazard Ratio: 3.5, 95% Confidence Interval: 1.3-9.4, p=0.01).


      RC is feasible in frail patients but is associated with increased perioperative morbidity and mortality. Preoperative frailty screening should be implemented to counsel and carefully select patients eligible for RC.

      Micro Abstract

      Studies about perioperative complications and all-cause mortality in frail patients requiring radical cystectomy (RC) are scarce. In this retrospective cohort study we identified individuals underwent RC (95 frail and 89 non-frail). RC in frail patients was associated with increased mortality and morbidity but it remains a feasible option.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Genitourinary Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Richters A
        • Aben KKH
        • Kiemeney LALM.
        The global burden of urinary bladder cancer: an update.
        World J Urol. 2020; 38: 1895-1904
        • Antoni S
        • Ferlay J
        • Soerjomataram I
        • Znaor A
        • Jemal A
        • Bray F.
        Bladder Cancer Incidence and Mortality: A Global Overview and Recent Trends.
        Eur Urol. 2017; 71: 96-108
        • Garg T
        • Young AJ
        • Kost KA
        • et al.
        Burden of Multiple Chronic Conditions among Patients with Urological Cancer.
        J Urol. 2018; 199: 543-550
        • Parikh N
        • Sharma P.
        Frailty as a prognostic indicator in the radical cystectomy population: a review.
        Int Urol Nephrol. 2019; 51: 1281-1290
        • Fonteyne V
        • Ost P
        • Bellmunt J
        • et al.
        Curative Treatment for Muscle Invasive Bladder Cancer in Elderly Patients: A Systematic Review.
        Eur Urol. 2018; 73: 40-50
        • Babjuk M.
        Bladder Cancer in the Elderly.
        Eur Urol. 2018; 73: 51-52
        • Geiss R
        • Sebaste L
        • Valter R
        • et al.
        Complications and Discharge after Radical Cystectomy for Older Patients with Muscle-Invasive Bladder Cancer: The ELCAPA-27 Cohort Study.
        Cancers. 2021; 13: 6010
        • Cathomas R
        • Lorch A
        • Bruins HM
        • et al.
        The 2021 Updated European Association of Urology Guidelines on Metastatic Urothelial Carcinoma.
        Eur Urol. 2022; 81: 95-103
        • von Elm E
        • Altman DG
        • Egger M
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Lancet Lond Engl. 2007; 370: 1453-1457
        • Rockwood K
        • Song X
        • MacKnight C
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        CMAJ Can Med Assoc J J Assoc Medicale Can. 2005; 173: 489-495
        • Doyle DJ
        • Goyal A
        • Garmon EH.
        American Society of Anesthesiologists Classification.
        StatPearls Publishing, 2022 (Accessed August 20, 2022)
        • Charlson ME
        • Pompei P
        • Ales KL
        • MacKenzie CR.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Froehner M
        • Brausi MA
        • Herr HW
        • Muto G
        • Studer UE.
        Complications following radical cystectomy for bladder cancer in the elderly.
        Eur Urol. 2009; 56: 443-454
        • van der Vlies E
        • Los M
        • Stijns PEF
        • et al.
        Preoperative frailty and outcome in patients undergoing radical cystectomy.
        BJU Int. 2020; 126: 388-395
        • Giannarini G
        • Kessler TM
        • Thoeny HC
        • Nguyen DP
        • Meissner C
        • Studer UE.
        Do patients benefit from routine follow-up to detect recurrences after radical cystectomy and ileal orthotopic bladder substitution?.
        Eur Urol. 2010; 58: 486-494
        • Nishiyama H
        • Habuchi T
        • Watanabe J
        • et al.
        Clinical Outcome of a Large-Scale Multi-Institutional Retrospective Study for Locally Advanced Bladder Cancer: A Survey Including 1131 Patients Treated during 1990–2000 in Japan.
        Eur Urol. 2004; 45: 176-181
        • Ploussard G
        • Shariat SF
        • Dragomir A
        • et al.
        Conditional survival after radical cystectomy for bladder cancer: evidence for a patient changing risk profile over time.
        Eur Urol. 2014; 66: 361-370
        • Chamie K
        • Hu B
        • Devere White RW
        • Ellison LM
        Cystectomy in the elderly: does the survival benefit in younger patients translate to the octogenarians?.
        BJU Int. 2008; 102: 284-290
        • Al Hussein Al Awamlh B
        • Wang LC
        • Nguyen DP
        • et al.
        Is continent cutaneous urinary diversion a suitable alternative to orthotopic bladder substitute and ileal conduit after cystectomy?.
        BJU Int. 2015; 116: 805-814
        • Pyrgidis N
        • Sokolakis I
        • Haltmair G
        • Hatzichristodoulou G.
        The effect of urinary diversion on renal function after cystectomy for bladder cancer: comparison between ileal conduit, orthotopic ileal neobladder, and heterotopic ileocecal pouch.
        World J Urol. 2022; 40: 3091-3097
        • Mally D
        • John P
        • Pfister D
        • Heidenreich A
        • Albers P
        • Niegisch G.
        Comparative Analysis of Elderly Patients Undergoing Radical Cystectomy With Ureterocutaneostomy or Ileal Conduit With a Special Focus on Bowl Complications Requiring Surgical Revision.
        Front Surg. 2022; 9803926
        • Malinaric R
        • Mantica G
        • Balzarini F
        • Terrone C
        • Maffezzini M.
        Extraperitoneal cystectomy with ureterocutaneostomy derivation in fragile patients - should it be performed more often?.
        Arch Ital Urol Androl Organo Uff Soc Ital Ecogr Urol E Nefrol. 2022; 94: 144-149
        • Krishnan N
        • Li B
        • Jacobs BL
        • et al.
        The Fate of Radical Cystectomy Patients after Hospital Discharge: Understanding the Black Box of the Pre-readmission Interval.
        Eur Urol Focus. 2018; 4: 711-717
        • Merten R
        • Ott O
        • Haderlein M
        • et al.
        Long-Term Experience of Chemoradiotherapy Combined with Deep Regional Hyperthermia for Organ Preservation in High-Risk Bladder Cancer (Ta, Tis, T1, T2).
        The Oncologist. 2019; 24: e1341-e1350
        • De Nunzio C
        • Cicione A
        • Izquierdo L
        • et al.
        Multicenter Analysis of Postoperative Complications in Octogenarians After Radical Cystectomy and Ureterocutaneostomy: The Role of the Frailty Index.
        Clin Genitourin Cancer. 2019; 17: 402-407
        • Minnella EM
        • Awasthi R
        • Bousquet-Dion G
        • et al.
        Multimodal Prehabilitation to Enhance Functional Capacity Following Radical Cystectomy: A Randomized Controlled Trial.
        Eur Urol Focus. 2021; 7: 132-138