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method for diversion seems to be of special importance. For
the frailest patients, cutaneous ureterostomy, possibly via a
extraperitoneal approach, could be a valid option. It does
not require bowel isolation and manipulation, has a shorter
operation time, and reduces the number of bowel and
metabolic complications while maintaining the radical
nature of the surgery and a reasonable quality of life .
A less invasive laparoscopic or robot-assisted approach
could reduce the perioperative burden for patients by
reducing blood loss, transfusion rates, and the length of
hospital stay For these reasons, minimally invasive
surgery has been suggested as potentially beneficial in
elderly patients. However, the definitive role of this
approach needs to be confirmed in prospective trials with
appropriately selected cases.
The role of perioperative chemotherapy in elderly
patients has not been well studied because of the expected
lower tolerability for cisplatin-based chemotherapy in frail
individuals. Indications for perioperative chemotherapy
must therefore be considered on an individual basis.
There is no doubt that high-quality surgery and
perioperative care, which should be concentrated in high-
volume centres, are essential for the best patient outcomes.
4. What is the role of alternative curative treatment
options?
The trimodal approach, involving a combination of trans-
urethral resection of the bladder with radiation and
systemic chemotherapy, is usually considered in patients
unwilling to undergo surgery or unfit for radical cystec-
tomy. In experienced hands, this approach is well tolerated
with outcomes similar to those for radical cystectomy,
which makes it a potentially interesting strategy for the
elderly population . It is also essential to concentrate on
adequate application and doses of radiation and systemic
chemotherapy, as the outcomes for patients who receive
suboptimal treatment are very poor .
5. How should we select optimal treatment for each
individual patient?
We all feel that the approach to frail patients with MIBC
must be strictly on a case-by-case basis. Unfortunately,
scientifically correct decisions are hampered by a lack of
evidence on results for individual treatment modalities in
each patient subpopulation. There is no doubt that the
elderly population is very heterogeneous and should not be
stratified by age but according to frailty status. Although
we have some tools and methods that can help us to
categorise patients, data on correlation with treatment
results are missing .
In conclusion, the treatment of elderly patients with
MIBC should be performed at a high professional level in
high-volume centres. Clinicians should respect the level of
frailty of each patient, but should follow all the criteria used
for younger individuals to the greatest extent possible. We
must urgently initiate prospective trials to help in unifying
the tools for stratification of patients according to their
frailty and in evaluating treatment results for individual
categories.
Conflicts of interest: The author has received lecture honoraria from
Astellas and Ipsen.
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