What is the best treatment for an elderly male with a 5.8 cm bladder mass and muscle-invasive disease complicated by frequent Urinary Tract Infections (UTIs)?

Treatment of Muscle-Invasive Bladder Cancer in an Elderly Male with Recurrent UTIs

Radical cystectomy with neoadjuvant cisplatin-based chemotherapy is the standard of care for this patient with muscle-invasive bladder cancer (MIBC), provided he is fit for surgery and has adequate renal function. 1

Primary Treatment Approach

Radical cystectomy remains the mainstay of treatment for muscle-invasive bladder disease. 1 For this 5.8 cm muscle-invasive tumor, surgical removal of the bladder offers the best chance for cure and addresses both the cancer and the source of recurrent UTIs.

Neoadjuvant Chemotherapy Considerations

• Cisplatin-based neoadjuvant chemotherapy improves overall survival in MIBC and should be administered before cystectomy in eligible patients. 1
• Critical prerequisite: Assess renal function before cisplatin administration, as it is contraindicated in patients with pre-existing renal impairment. 2
• In elderly patients, cisplatin is substantially excreted by the kidney, and elderly patients are more susceptible to nephrotoxicity, myelosuppression, and infectious complications. 2
• Monitor for dose-limiting nephrotoxicity (occurs in 28-36% of patients), ototoxicity (up to 31% of patients), and peripheral neuropathy. 2

Special Considerations for Elderly Patients

• Given his age and recurrent UTIs, perform comprehensive geriatric assessment including evaluation for frailty, comorbidities, and functional status before proceeding with aggressive treatment. 3
• Elderly patients (>70 years) with multimorbidity require careful consideration of treatment-related morbidity versus potential survival benefit. 3

Management of Recurrent UTIs

Pre-operative UTI Management

• Treat active UTIs with appropriate antibiotics before any surgical intervention. 3
• For elderly patients with recurrent UTIs, antimicrobial treatment generally aligns with standard protocols using fosfomycin, nitrofurantoin, pivmecillinam, or cotrimoxazole, unless complicating factors are present. 3
• Avoid fluoroquinolones for prophylaxis in elderly patients due to increased adverse effects and potential drug interactions with other medications. 3
• Consider that the bladder mass itself is likely the source of recurrent UTIs, making definitive surgical treatment even more important. 4

Diagnostic Pitfalls to Avoid

• Do not delay cancer treatment to repeatedly treat UTIs, as this pattern of UTI treatment is associated with delayed BC diagnosis and more advanced disease. 5
• Recognize that in elderly patients, UTI symptoms may be atypical (altered mental status, functional decline, falls) rather than classic dysuria and frequency. 3
• Ensure proper UTI diagnosis in elderly patients—mere bacteriuria does not confirm UTI due to high prevalence of asymptomatic bacteriuria in this population. 3, 6

Alternative Treatment Pathways

If Patient is NOT a Surgical Candidate

• For patients unfit for radical cystectomy due to comorbidities or frailty, consider bladder-preserving approaches, though these are associated with inferior outcomes compared to cystectomy. 1
• Palliative management may be appropriate for patients with limited life expectancy or severe frailty, focusing on symptom control and quality of life. 3

Critical Safety Monitoring

• Before initiating any treatment, obtain baseline renal function (creatinine clearance), complete blood count, and audiometric testing if chemotherapy is planned. 2
• Monitor for complications of bladder mass including hematuria, urinary retention, and progression of UTIs to pyelonephritis or urosepsis. 4
• Review all current medications for drugs that may worsen urinary symptoms or interact with chemotherapy agents. 7, 8

Urinary Diversion Considerations

• Urinary diversion after cystectomy is a major cause of morbidity in elderly patients, requiring careful discussion of options and realistic expectations. 1
• The choice between ileal conduit versus continent diversion should consider the patient's functional status, manual dexterity, cognitive function, and ability to manage the diversion. 1

Immediate Referral Indications

This patient requires urgent urology referral for:

• Large (5.8 cm) muscle-invasive bladder mass requiring definitive oncologic management 1
• Recurrent UTIs in the setting of bladder pathology 7, 8
• Potential for acute urinary retention or obstructive uropathy from the large mass 4