# Chronological and biological age stratify survival after robot-assisted radical cystectomy for bladder cancer: a pragmatic age-ECOG risk score

## TL;DR

Older age and poor health status are linked to worse survival after bladder cancer surgery, suggesting a new risk score could help guide treatment decisions.

## Contribution

A new pragmatic age-ECOG risk score is proposed to better predict survival after robot-assisted radical cystectomy.

## Key findings

- Survival after surgery worsens significantly for patients over 76.5 years old.
- ECOG performance status ≥2 is strongly associated with reduced overall survival.
- The age-ECOG score effectively separates patients into distinct survival groups.

## Abstract

Chronological age influences selection for radical cystectomy in bladder cancer, yet biological vulnerability may be more informative. We assessed perioperative outcomes and overall survival after robot-assisted radical cystectomy (RARC) and developed a pragmatic age–Eastern Cooperative Oncology Group (ECOG) risk score.

Consecutive RARC patients (August 2013–December 2024) were analyzed retrospectively and grouped by age (< 75, 75–79, 80–84, ≥ 85 years). Ninety-day complications were graded by Clavien–Dindo classification. Overall survival (OS) was estimated by Kaplan–Meier methods. An age threshold for overall mortality was derived by receiver operating characteristic analysis (Youden index). The risk score assigned one point each for age above the cut-off and ECOG performance status ≥ 2. Cox regression adjusted for Charlson Comorbidity Index and pathological T stage.

Among 171 patients, length of stay and overall complications did not differ statistically across age strata, although comparisons are limited by selection and the small ≥ 85 subgroup. OS differed by age cohort (p = 0.00013) with an optimal age threshold of 76.5 years (p < 0.0001). ECOG ≥ 2 predicted worse survival (p < 0.0001), and the score separated 1, 2 and 3 score groups (p < 0.0001). On multivariable analysis, age > 76.5 years remained independently associated with worse overall survival (hazard ratio 2.72, 95% confidence interval 1.58–4.68; p < 0.001).

RARC is feasible across advanced age strata in selected patients, but survival varies substantially. A simple age threshold plus ECOG performance status may aid counseling and perioperative planning and warrants external validation.

The online version contains supplementary material available at 10.1007/s00345-026-06294-4.