Limitations and challenges of uro-oncologic surgery in elderly patients: A critical review of the management of prostate, bladder and kidney cancer

Due to the increase in life expectancy, challenging scenarios in oncogeriatrics are becoming more common in clinical practice. The outcomes of curative cancer treatments, which have shown benefits in the general population, are not always studied in elderly patients. Chronological age alone may not accurately correlate with the risk of complications or the potential benefit in survival, in contrast to the increasingly used frailty scores. Therefore, an adequate preoperative comprehensive geriatric assessment is essential. This review addresses the challenge of decision-making regarding surgical treatment of the most frequent urological cancers in elderly patients. Prostate cancer in elderly patients implies a complex scenario; life expectancy represents a determining factor given its often indolent behavior, in order to avoid overtreatment. It is crucial to face this challenge focusing on cancer screening primarily. In the literature, there are heterogeneous data regarding survival, although a similar rate of surgical complications and worse functional outcomes than younger patients have been reported. Muscle-invasive bladder cancer in the elderly also represents a challenge, because of the high rate of complications of radical cystectomy and the evidence of lower overall and cancer-specific survival in this group of patients. Finally, the key elements in the management of kidney cancer in elderly patients who are candidates for surgical treatment are the need to preserve renal function (considering nephron-sparing surgery) and the limited data regarding benefit in overall survival. For this reason, active surveillance of small renal masses can be a useful strategy.