Robot-assisted radical cystectomy in octogenarians.

BACKGROUND AND PURPOSE: Radical cystectomy is the standard of care for muscle-invasive bladder cancer; however, few patients over age 75 undergo cystectomy. Morbidity and mortality rates in this age group approach 60% and 10%, respectively. We sought to determine if minimally invasive surgery, in the form of robot-assisted radical cystectomy (RARC), may reduce morbidity and mortality associated with this operation in elderly patients. PATIENTS AND METHODS: After Institutional Review Board approval, all RARC performed between 2009 and 2012 from one institution were reviewed, and 23 cases in patients over the age of 80 were identified. Data analyzed included age, indication for cystectomy, American Society of Anesthesiologists score (ASA), Charlson Comorbidity Index, pathologic stage, estimated blood loss, transfusion rate, and 90-day morbidity and mortality rate. RESULTS: Twenty-three patients over the age of 80 years underwent RARC by a single surgeon (IT) between April 2009 and October 2012. Average age was 83.7 years (range 80-88 years) with average Charlson Comorbidity Index score of 4.3 (age-weighted 8.3). Indication for cystectomy was oncologic in all cases (21 bladder malignancy, 2 hemorrhagic cystitis in the setting of prostate cancer). The average blood loss and operative times were 208 mL (range 50-650 mL) and 253 minutes (range 175-365 min). Seven (30.4%) patients needed blood transfusions. The average length of hospital stay was 8.2 days (range 6-24 days). The overall complication rate within 90 days was 34.8% (8 patients) with no mortality. Longest follow-up is 34 months. CONCLUSIONS: RARC should be strongly considered for patients over the age of 80 with clinical indications for cystectomy. The complication rate is acceptable even in complicated patients with multiple comorbidities and those with previous abdominal surgery or pelvic radiation. Hospital stay remains shorter than with open surgery, and complication rates appear to be lower than previously reported for this age group.

Living-donor renal transplantation of grafts with incidental renal masses after ex-vivo partial nephrectomy.

OBJECTIVES: To assess transplantation of high-risk kidneys with incidental renal masses (found occasionally during the routine evaluation of a living kidney donor) into recipients with limited life-expectancy on haemodialysis, as this offers a potential solution to the current organ deficit. PATIENTS AND METHODS: We detected five small (<2.3 cm), incidental, enhancing renal masses during donor evaluation. All patients had a standard metastatic evaluation. After laparoscopic donor nephrectomy a back-table partial nephrectomy was performed and frozen-section analysis was used to confirm both the diagnosis and negative surgical margins before transplantation. RESULTS: Renal cell carcinoma was found in three of the five masses (one each cystic, clear cell and papillary; Fuhrman grades II, II and III, respectively) and the other two patients had angiomyolipoma. There were no long-term complications in the transplanted kidneys. One patient developed delayed acute humoral rejection after transplantation and was treated appropriately. Both donor and recipient were followed with periodic imaging. At a median (range) last follow-up of 15 (1-41) months, four patients were alive and one had died from complications after a fall. The cancer-specific survival was 100%. There was no evidence of local recurrence in any patient at the last follow-up. CONCLUSION: Live donor kidneys with incidental small renal masses might be acceptable for transplantation in high-risk recipients after careful back-table partial nephrectomy.