Elderly Patients' Outcomes After Robot-Assisted Radical Prostatectomy: A Single Center Experience

Abstract

Aim:

To assess the oncological and functional outcomes of patients aged 70 years or older after robot-assisted radical prostatectomy (RARP) and compare their results with younger men.

Materials and Methods:

Our study included 496 men who underwent RARP in our clinic between March 2015 and December 2021 with at least 1-year follow-up. Of these patients, 130 were aged 70 or older, and 366 were between 60 and 69. Preoperative characteristics, perioperative parameters, postoperative oncological, and functional results were studied.

Results:

The entire cohort (496 patients) aged 67 years on median (range 60–84), with a median prostate-specific antigen of 8.4 ng/mL. All the patients had a minimum 1-year of follow-up and the median follow-up was 32 months. According to the perioperative parameters, the two groups were similar except for hospital length of stay. On final pathology, the pathological stage, positive surgical margin rate and lymph node positivity were statistically not different between the two groups. The International Society of Urological Pathology grades were higher on final pathology for both groups, but this increase was greater in the ≥70 age group, and this was statistically significant (P = .013). In both groups, the median International Index for Erectile Function scores decreased after surgery significantly (P < .001), and at the 1st year follow-up, the decrease between the two groups was not different (0.973). Concerning continence outcomes, pad-free continence was significantly better in the 60–69 age group (94.5%) compared to the ≥70 age group (93.1%).

Conclusions:

The perioperative safety, oncological, and functional results of RARP in elderly men are comparable to younger patients.

Clinical trial registiration number: (30/06/2022-13/24)

Introduction

Worldwide, prostate cancer (PCa) is the second most commonly diagnosed cancer and the fifth leading cause of cancer death among men.¹ Radical prostatectomy is the only surgical treatment for localized PCa, and with technological developments, 85% of radical prostatectomies have become robot-assisted 10 years after its introduction.² During the last decade, life expectancy has been prolonged 2–5 years in European countries and the United States.³

As a result of increased life expectancy, the diagnosis and treatment of PCa in elderly patients are increasing. Only assessment of chronological age in this cohort of patients can result in undertreatment of men who could have benefitted from definitive treatment.⁴ Therefore, some geriatric tools have been developed to distinguish fit patients from unfit ones, but none is superior to another. Also, there are tools to calculate the life expectancy of patients, but those are not widely accepted since the calculation is a little rough. Taken together, it has been difficult to decide on surgery, with the growing use of minimally invasive procedures like robot-assisted radical prostatectomy (RARP), there have been significant trends to operate the elderly patients, and feasible oncologic and functional outcomes were reported.^5–7

The definition of “elderly” patient is not clear according to most clinical guidelines and most of the studies worldwide use a cut-off value of around 65–70 years but according to the International Society of Geriatric Oncology, patients should be managed by using geriatric assessment tools instead of their chronological age.⁸ We sought to assess the oncological and functional outcomes of patients aged 70 years or older after RARP in our tertiary-referral hospital and compare their results with younger patients.

Materials and Methods

Our study included 496 men who underwent RARP in our clinic between March 2015 and December 2021 with at least 1-year follow-up. Of these patients, 130 were aged 70 or older and 366 were between 60 and 69.

Surgeries were performed by two surgeons via transabdominal approach as described before.⁹ Perioperative parameters such as operation time, intraoperative complications, and whether lymph node (LN) dissection or nerve-sparing was done were recorded. Operation time was defined as a skin-to-skin time in minutes and included the docking and undocking time. Postoperative parameters including hematocrit change, duration of hospitalization, and catheter removal date were noted. Pathological outcomes included pathological Gleason score; positive surgical margin (PSM) status; extracapsular, lymphovascular, perineural, and seminal vesicle invasion; as well as LN positivity. To classify the complications after surgery, the Clavien–Dindo system, which provides standardization in the literature, was used.¹⁰ To assess potency, we used International Index for Erectile Function short form (IIEF-5), and continence was defined as pad-free status. While comparing preoperative and postoperative functional results, we excluded patients who received radiotherapy or adjuvant hormone therapy within one year after surgery.

Patient data were reviewed from a prospectively registered specific database and analyzed retrospectively. Institutional review board approval was obtained (30/06/2022-13/24) before this study, and all patients gave written informed consent documents.

Statistical analysis

Descriptive statistics are presented as frequency, percentage, mean, standard deviation, median, minimum, maximum, and 25%–75% percentile (Q1–Q3) values. Normality assumption was checked by examining the histogram, q–q plot, skewness, and kurtosis values with Shapiro–Wilk test. Mann–Whitney U test was used to analyze the difference between the numerical data of the two groups because the data did not fit the normal distribution. Pearson's Chi-Square was used when the proportion of cells with an expected value less than 5 was less than 20%, and Fisher's Exact Test was used when the expected value was greater than 20%. Wilcoxen Signed Rank Test was used to evaluate the differences between dependent measures. The relationships between the numerical data were evaluated with Spearman's Correlation Test since the data did not fit the normal distribution. In the analysis, IBM SPSS 23.0 for Windows (IBM Corp., Armonk, NY) was used, and cases where the P values <.05 were considered statistically significant.

Results

The entire cohort (496 patients) was aged 67 years on median (range 60–84), with a median prostate-specific antigen of 8.4 ng/mL. All the patients had a minimum 1-year of follow-up, and the median follow-up was 32 (Q1 26, Q3 42) months. There were no 90-day mortalities in either group.

Preoperative clinical characteristics of both groups are shown in Table 1 separately. The two groups were similar except for the prostate volume, body mass index, and preoperative scores of the American Society of Anesthesiologists (ASA). According to the International Society of Urological Pathology (ISUP) grading, there was no difference between the two groups before surgery.

Table 1.

Patient Characteristics

Variable	Age 60–69 (n = 366)	Age ≥70 (n = 130)	P
Age, year, median (IQR)	65(63–67)	72(70–73)	<0.001
Weight, kg, median (IQR)	80 (73–88)	76 (69–84)	0.001
Height, m, median (IQR)	1.71 (1.65–1.75)	1.72 (1.68–1.75)	0.752
BMI, kg/m², median (IQR)	27.34 (24.49–29.41)	25.71(23.88–28.08)	0.001
Prostate volume, cc, median (IQR)	45 (35–60)	50 (40–65)	0.029
Preoperative prostate-specific antigen, ng/mL, median (IQR)	8 (6–12.5)	9.34 (6.41–13.32)	0.075
ASA score, n (%)
1	67 (18.3)	8 (6.2)	<0.001
2	219 (59.8)	63 (48.5)
3	80 (21.9)	59 (45.4)
Additional diseases (diabetes mellitus, cardiovascular disease), n (%)	192 (52.5)	64 (49.2)	0.527
Continuous anticoagulant or antiaggregant use, n (%)	96 (26.2)	24 (18.5)	0.076
Metabolic syndrome, n (%)	37 (10.1)	12 (9.3)	0.792
Preoperative ISUP, n (%)
1	228 (62.29)	73 (56.15)	0.991
2	66 (18.03)	33 (25.38)
3	33 (9.01)	11 (8.46)
4	30 (8.19)	11 (8.46)
5	9 (2.45)	2 (1.53)

p values < 0.05 were considered statistically significant.

ASA, American Society of Anesthesiologists; BMI, body mass index; IQR, interquartile range; ISUP, International Society of Urological Pathology.

Perioperative parameters are shown in Table 2; the two groups were similar except for hospital length of stay. Duration of hospitalization was longer in the ≥70 age group (P < .001). The mean operation time was 217 ± 78 (Q1 150, Q3 260) minutes for the entire cohort, and lymph node dissection (LND), which is a factor that may affect this, was equally distributed in both groups.

Table 2.

Perioperative Characteristics

Variable	Age 60–69 (n = 366)	Age ≥70 (n = 130)	P
Lymph node dissection, n (%)	143 (39.1)	60 (46.2)	0.158
Major vascular complication, n (%)	16 (4.4)	3 (2.3)	0.426
Intraoperative organ injury, n (%)	18 (4.9)	4 (3.1)	0.381
Operation time, minutes, median (IQR)	205 (150–250)	192.5 (150–270)	0.381
Estimated blood loss, mL, median (IQR)	300 (200–400)	250 (200–350)	0.492
Duration of hospitalization, days, median (IQR)	3 (3–4)	4 (3–4)	<0.001
Intraoperative ES replacement, n (%)	10 (2.7)	4 (3.1)	0.766

p values < 0.05 were considered statistically significant.

ES, erythrocyte suspension; IQR, interquartile range.

Postoperative pathological outcomes and clinical follow-up are shown in Table 3. On final pathology, the pathological stage (pT), PSM rate, and LN positivity were statistically not different between the two groups. The ISUP grades were higher on final pathology for both groups, but this increase was greater in the ≥70 age group and this was statistically significant (P = .013). The biochemical recurrence (BCR) rate was higher in the ≥70 age group, but this was not statistically significant (P = .158). The time to BCR was significantly longer in the ≥70 age group (P = .004) as well as the follow-up period of this group (P < .001).

Table 3.

Postoperative Pathological Characteristics and Clinical Follow-Up Outcomes

Variable	Age 60–69 (n = 366)	Age ≥70 (n = 130)	P
Postoperative ISUP, n (%)
1	132 (36.06)	38 (29.23)	0.078
2	129 (35.24)	44 (33.84)
3	53 (14.48)	26 (20.0)
4	25 (6.83)	9 (6.9)
5	27 (7.37)	13 (10.0)
Pathologic staging, n (%)
t2a	51 (13.9)	14 (10.8)	0.326
t2b	49 (13.4)	10 (7.7)
t2c	138 (37.7)	53 (40.8)
t3a	79 (21.6)	31 (23.8)
t3b	49 (13.4)	22 (16.9)
Extraprostatic extension, n (%)	120 (32.8)	47 (36.2)	0.485
Lymphovascular invasion, n (%)	73 (19.9)	27 (20.8)	0.841
Perineural invasion, n (%)	277 (75.7)	106 (81.5)	0.172
Seminal vesicle invasion, n (%)	50 (13.7)	22 (16.9)	0.364
Positive surgical margin, n (%)	92 (25.1)	34 (26.2)	0.819
Lymph node metastasis, n (%)	22 (6.0)	3 (2.3)	0.096
Biochemical recurrence, n (%)	44 (12.0)	22 (16.9)	0.158
Time to recurrence, median, months	28	32	0.004
Follow-up period, median, months	29	38	<0.001

p values < 0.05 were considered statistically significant.

ISUP, International Society of Urological Pathology.

A comparison of preoperative and postoperative functional characteristics is shown in Table 4. In both groups, the median IIEF scores decreased after surgery significantly (P < .001), and at the first-year follow-up, the decrease between the two groups was not different (0.973). Concerning continence outcomes, pad-free continence was significantly better in the 60–69 age group (94.5%) compared to the ≥70 age group (93.1%).

Table 4.

Comparison of Preoperative and Postoperative Functional Characteristics

Variable	Age 60–69 (n = 366)	Age ≥70 (n = 130)	P
Preoperative IIEF total score, median (IQR)	15 (10–20)	12 (8–17)	0.003
Postoperative IIEF total score (1st year), median (IQR)	7 (5–12)	5 (5–9)	<0.001
Urinary incontinence (1st year), n (%)
Yes	20 (5.5)	9 (6.9)	0.005
No	346 (94.5)	121 (93.1)
Pad count (if incontinence exists), median (IQR)	1 (1–1)	2 (1–3)	0.005

p values < 0.05 were considered statistically significant.

IIEF, international index of erectile function; IQR, interquartile range.

Discussion

The general approach among urologists is to recommend radical prostatectomy to patients who have a life expectancy of more than 10 years. Therefore, it was not traditionally considered a treatment option for patients over 70 years old. However, with the increasing population of elderly men in developed countries, chronological age is no longer a stand-alone obstacle to surgery.

Robot-assisted surgery has become 85% of radical prostatectomies worldwide, and perioperative outcomes and safety have been studied in many articles in elderly men. Rogers et al. evaluated the feasibility and safety of RARP in men over 70 years of age with high-risk PCa and reported that RARP appears to have the same perioperative and short-term postoperative outcomes with men under 70 years.¹¹ Yamada et al. compared the perioperative outcomes of men over 75 years of age with younger men undergoing RARP and reported that there is no difference in terms of complications and perioperative outcomes, although preoperative ASA scores were significantly higher in the elderly men.¹² In our study, operation time, perioperative complications, and estimated blood were the same for elderly and younger men. Only, the duration of hospitalization was 1 day more in the elderly patients, although the interquartile range was the same for both groups.

The potential benefit of surgery in the elderly population depends on the presence of more aggressive tumors reported in the literature which may lead to a significant cancer-specific mortality.^13,14 For this reason, a curative treatment for localized PCa should be recommended to these patients, and the options are surgery or radiotherapy. It has been well established that the oncological outcomes of radical prostatectomy in elderly men are not different than younger. Labanaris et al. reported perfect oncological and functional results with limited complications and 95.5% of their patients were BCR-free with a median 17.2-month follow-up.¹⁵ Lu-Yao et al. pointed out cancer-specific mortality rates after 15 years of 10%–27%, depending on the Gleason score, and concluded that elderly men might benefit from radical prostatectomy rather than conservative management.¹⁶

In our study, preoperative ISUP grades were not different in the elderly group, and postoperative ISUP grades were higher on final pathology for both groups, but the difference was not significant. The pT, PSM, and LN positivity did not differ in the elderly group, and the BCR rate was similar to younger patients. So considering the potential side effects of radiotherapy (rectal symptoms and irritative urinary symptoms) and hormonal therapy (metabolic syndrome, osteoporosis, cardiovascular toxicity, etc.) RARP seems to be a safe and effective treatment in elderly men.

Although the functional results after RARP decrease with advancing age, the published articles suggest that the parameters in the elderly are quite acceptable. Shikanov et al. reported the probability of continence 1-year after surgery at age 65, 70, and 75 years as 0.66, 0.63, and 0.59, respectively. In the same study, predicted probabilities of postoperative 1-year potency after bilateral nerve-sparing were 0.66, 0.56, and 0.46.¹⁷ Yadav et al. compared the functional outcomes of patients over 70 years with younger ones and declared that the continence rates for the elderly at 6 months and 1-year follow-up were 87.9% and 94.8%, respectively, while these rates were 91.4% and 93.6% for men under 70, respectively.¹⁸ They concluded that the delay in return to continence of elderly men may depend on the difference in tissue resiliency compared with younger.

Many factors can affect the continence and potency status after RARP such as baseline International Prostate Symptom Score and IIEF scores, surgical technique, nerve-sparing grade, and additional diseases. Large studies usually do not take into account such multiple variables since it is difficult to distinguish them. So single-center studies with lower numbers can assess the outcomes better by avoiding confounding factors. In our study, after a 1-year follow-up, 93.1% of men over 70 years and 94.5% of men between 60–69 years were pad-free continent, which was statistically significant. In terms of potency, after multivariate analysis, Gurung et al. reported that age and nerve-sparing status were significant predictors of postoperative erectile dysfunction and with the same degree of nerve-sparing younger men have better postoperative erection.⁷ Kumar et al. declared that a greater proportion of younger men became potent than the elderly at 2 years (52.3% versus 33.5%, respectively) since the average time for return of potency was 6 months.¹⁹

In our study, the IIEF scores decreased for both the elderly and younger men at 1 year, but the decrease was not different statistically between groups. This may depend on the same ratio of nerve-sparing in the elderly group since ISUP scores were not different from younger men.

There are several limitations of our study. First, this is a retrospective nonrandomized study, although the data are derived from a prospectively registered database. Second, our single-center study with a small sample size may not reflect the whole society. However, it has the advantage of uniform operative and postoperative protocols. Additionally, our study needs longer follow-up data which may predict better oncological results.

Conclusion

The perioperative safety, oncological, and functional results of RARP in elderly men are comparable to younger patients. Therefore, chronological age alone should not deprive elderly men of the benefits of RARP.

Footnotes

Acknowledgment

The authors would like to thank Dr. Deniz Ozel and appreciate her support for the statistical analysis of this study.

Authors' Contributions

E.I.: Conceptualization (equal), writing—review and editing (lead). E.E.A.: Conceptualization (equal), writing–original draft (supporting), data curation (lead). S.T.: Data curation (supporting), methodology (equal), software (equal). O.A.: Software (equal), Data curation (supporting). M.S.B.: Writing—original draft (supporting), Validation (lead). M.A.: Writing—review and editing (supporting). M.S.: Writing—review and editing (supporting).

Disclosure Statements

No competing financial interests exist.

Funding Information

No funding was received for this article.

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