Cytoreductive nephrectomy in the elderly: a population-based cohort from the USA

Study Type Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? While cytoreductive nephrectomy is associated with a survival benefit in the context of metastatic renal cell carcinoma, the rates of morbidity and perioperative mortality remain non-negligible. For example, perioperative mortality may be as high as 21% in elderly patients. The study shows that perioperative death amongst the elderly was substantially lower than what was previously reported from a single institutional report. Nonetheless, postoperative adverse outcomes were non-negligible in elderly patients relative to their younger counterparts. In consequence, these rates should be discussed at informed consent and a rigorous patient selection remains essential. OBJECTIVE To examine the rate of perioperative mortality (PM), and other adverse outcomes in elderly patients treated with cytoreductive nephrectomy (CNT). MATERIAL AND METHODS Patients who underwent CNT for metastatic renal cell carcinoma were abstracted from the Nationwide Inpatient Sample (19982007). Elderly was defined as =75 years, according to previous definition. Endpoints consisted of PM, intraoperative and postoperative complications, blood transfusions and length of stay. We adjusted for the effect of elderly status within five separate logistic regression models. Covariates consisted of comorbidity, race, gender, year of surgery and hospital region. RESULTS Overall, CNT was performed in 504 (15.3%) elderly patients and in 2796 (84.7%) younger patients (<75 years). The rate of PM was 4.8% in elderly patients vs 1.9% in the younger patients (P < 0.001). Similarly, the rates of blood transfusions (29.8 vs 21.5%), postoperative complications (27.8 vs 22.8%), and prolonged length of stay (=8 days) were higher in the elderly (45.0 vs 32.0%; all P < 0.001). In multivariable analyses, elderly patients were 2.2-, 1.5-, and 1.6fold more likely to experience PM, to receive a blood transfusion and to be hospitalized =8 days than the younger patients. CONCLUSIONS Although the rate of PM was substantially lower than 21%, elderly patients are significantly more likely to die after this type of surgery, to receive a transfusion, and to experience a prolonged length of stay. These facts and figures should be discussed at informed consent and a rigorous patient selection is essential.