Impact of the Modified Frailty Index-5 on Treatment Selection and Prognosis in Octogenarians with Bladder Cancer Eligible for Radical Cystectomy: A Single-center, Retrospective Study 

Impact of the Modified Frailty Index-5 on Treatment Selection and Prognosis in Octogenarians with Bladder Cancer Eligible for Radical Cystectomy: A Single-center, Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of the Modified Frailty Index-5 on Treatment Selection and Prognosis in Octogenarians with Bladder Cancer Eligible for Radical Cystectomy: A Single-center, Retrospective Study Hayato Hoshina, Toru Sugihara, Masayuki Kurokawa, Ei-ichiro Takaoka, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9059441/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background Developing treatment strategies for bladder cancer in octogenarians remains challenging owing to concerns regarding surgical invasiveness and the risk of undertreatment. We aimed to evaluate the effect of the modified Frailty Index-5 score on treatment selection and prognosis in this population. Methods We retrospectively analyzed 44 patients with bladder cancer aged ≥ 80 years who were candidates for radical cystectomy. The patients were stratified into three groups: robot-assisted radical cystectomy (n = 10), non-surgical treatment (n = 24), and observation (n = 10). Results Multivariate analysis revealed that compared with chronological age or sex, surgical selection was strongly influenced by the modified Frailty Index-5 status (odds ratio 0.31), suggesting that frailty assessment plays a crucial role in clinical decision making. Overall survival did not differ significantly among the groups (p = 0.11); however, the robot-assisted radical cystectomy group showed a trend toward improved survival compared with the non-surgical treatment (hazard ratio [HR] 4.93; p = 0.054) and observation (HR 2.43; p = 0.38) groups. Conclusions Robot-assisted radical cystectomy appears to be a safe and feasible treatment option for carefully selected octogenarian patients. The modified Frailty Index-5 may serve as a practical and objective tool to support treatment decision making, helping avoid undue risk aversion based solely on chronological age. Bladder cancer mFI-5 Octogenarians RARC Robot surgery Figures Figure 1 Figure 2 Background Radical cystectomy remains the gold standard treatment for invasive or high-risk recurrent bladder cancer [ 1 ]. With the widespread adoption of robot-assisted radical cystectomy (RARC), surgical indications have expanded owing to its reduced invasiveness compared with that via open surgery [ 2 – 4 ]. Nevertheless, radical cystectomy is associated with substantial morbidity and a reported 5-year survival rate of approximately 50% [ 5 – 9 ]. Additionally, urinary diversion requirement can significantly affect patients’ quality of life, including body image and long-term urinary management. Therefore, careful patient selection is essential to balance the oncological benefits with the postoperative risk [ 10 ]. In rapidly aging societies, the incidence of invasive bladder cancer among octogenarians is steadily increasing, presenting unique therapeutic challenges [ 10 ]. Surgery is often considered the optimal approach for local disease control; however, older patients face competing risks, including cognitive impairment and physical frailty [ 11 , 12 ]. These factors increase the likelihood of postoperative complications, difficulties in stoma management, and a decline in activities of daily living. However, decisions regarding surgical eligibility in this population lack standardized criteria and rely heavily on subjective clinical judgments or patient preference [ 1 ], and objective and practical frailty assessment tools are needed to address this uncertainty. Although use of the modified Frailty Index-5 (mFI-5) is particularly attractive owing to its simplicity and reliance on routinely available clinical information [ 13 , 14 ], limited data exist regarding its role in guiding real-world treatment selection in extremely elderly individuals. Therefore, in this study, we aimed to retrospectively evaluate the impact of mFI-5 status on treatment decision making in octogenarians with bladder cancer and to assess overall survival (OS) in patients selected for RARC based on this stratification. Methods Patients Between January 2018 and December 2025, 146 patients aged ≥ 80 years underwent transurethral resection of a bladder tumor (TURBT) at Jichi Medical University Hospital. The study population comprised 44 patients deemed candidates for radical cystectomy during this period or who underwent TURBT at another institution during the same period and were subsequently referred to our hospital with the same diagnosis. We included patients (1) diagnosed with muscle-invasive bladder cancer (≥ pathological tumor (pT) 2) based on pathological findings, (2) deemed suitable for cystectomy owing to non-response to Bacilli Calmette-Guerin (BCG) therapy, and (3) diagnosed with pT1 variant bladder cancer [ 1 ]. We excluded cases involving distant metastasis or non-cancerous pathological diagnoses (malignant lymphoma). This was a single-center, retrospective study. Ethical Considerations This study was approved by the Institutional Review Board of the Jichi Medical University Hospital (approval no. A22-023). Written informed consent was obtained from all participants before their inclusion in the study. Data Collections The patients were classified into three groups based on the documented treatment history in their medical records: radical cystectomy, non-surgical treatment, and observation (those who did not undergo treatment after TURBT) groups. All patients in the radical cystectomy group underwent RARC using the da Vinci System (Intuitive Surgical Inc., Sunnyvale, CA, USA). Patients in the non-surgical treatment group received chemoradiotherapy, radiotherapy, or chemotherapy alone. The mFI-5 score was calculated based on the presence of any of the following comorbidities at the time of surgery: history of congestive heart failure within 30 days before surgery; presence of insulin-dependent or non-insulin-dependent diabetes; history of long-term obstructive pulmonary disease or pneumonia; dependence on complete or partial functional health status; and presence of hypertension requiring medication. Based on previous findings, mFI-5 was classified as ≥ 2 points (high group) or < 2 points (low group) [ 13 , 15 ]. End Points First, we evaluated the factors influencing surgical treatment selection, focusing on the impact of mFI-5. Second, we assessed OS to explore the association between the treatment strategy and prognosis in this cohort. Statistics Analysis For univariate analysis, categorical and continuous data were compared using the chi-squared and Mann–Whitney U test, respectively. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with RARC selection. The variables included in the model were age, sex, and the mFI-5, dichotomized as < 2 versus ≥ 2. The results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). OS was estimated using the Kaplan–Meier method, and differences between groups were assessed using the log-rank test. To explore the association between treatment strategy and prognosis, we performed Cox proportional hazards regression analysis and calculated hazard ratios (HRs) with 95% CIs. Given the limited number of events, the primary variables of the Cox regression model were the treatment modality and age. Other clinical variables, including mFI-5, were not included in the multivariable Cox model to avoid overfitting owing to the limited number of events. For sensitivity analysis, we excluded patients under observation without active treatment, and reanalyzed survival outcomes by comparing the radical cystectomy and non-surgical treatment groups. We also used the Kaplan–Meier method to evaluate OS in the high- and low-risk groups based on the mFI-5 scores. All statistical analyses were performed using JMP version 17 (SAS Institute, Cary, NC, USA), and statistical significance was set at p < 0.05. Results Table 1 shows a summary of the patient characteristics. Overall, 44 patients were enrolled and stratified into the RARC (n = 10), non-surgical treatment (n = 24), and observation (n = 10) groups. The median age was significantly higher in the observation group (87 years) than in the RARC (82 years) and non-surgical treatment (81 years) groups (p < 0.05). Regarding frailty status, there were no statistically significant differences in the individual mFI-5 components or total scores among the three groups. However, the proportion of patients with an mFI-5 score ≥ 2 was lowest in the RARC group (40%), compared with those in the non-surgical treatment (66.7%) and observation (70%) groups. This difference was not statistically significant (p = 0.28). In the RARC group, four patients (40%) had pathological T1 disease. Indications for RARC included variant histology (n = 1) and BCG failure (n = 3). The breakdown of the non-surgical treatment group was as follows: chemoradiotherapy, radiotherapy, and chemotherapy alone in 8, 13, and 3 cases, respectively. Notably, the median follow-up duration differed significantly between the groups (p < 0.05), with the longest in the RARC group (27 months) and shortest in the observation group (6 months). Table 1 Patient characteristics across all populations (n = 44) Parameter RARC group, n = 10 Non-surgical treatment group, n = 24 Observation group, n = 10 P value Sex, male, n (%) 7 (70) 19 (79.2) 7 (70) 0.78 Age, years (IQR) 82 [80–83] 81 [81–84] 87 [83–91] 0.0056* Body mass index, (IQR) 24.4 [22.6–27.3] 22.9 [19.9–26.2] 21.5 [20.6–23.8] 0.37 ASA-PS, n (%) 0.34 1 0 (0) 1 (4.2) 0 (0) 2 9 (90) 13 (54.2) 6 (60) 3 1 (10) 10 (41.6) 4 (40) Component mFI-5, n (%) History of congestive heart failure 0 (0) 2 (8.3) 0 (0) 0.42 History of COPD or pneumonia 4 (40) 4 (16.7) 5 (50) 0.11 Totally or partially dependent functional health status 0 (0) 6 (25) 2 (20) 0.22 Hypertension requiring medication 8 (80) 19 (79.1) 8 (80) 1 Diabetes mellitus 2 (20) 9 (37.5) 2 (20) 0.45 mFI-5 score, n (%) 0.34 0 0 (0) 3 (12.5) 1 (10) 1 6 (60) 5 (20.8) 2 (20) 2 4 (40) 14 (58.4) 6 (60) 3 0 (0) 2 (8.3) 1 (10) mFI-5 ≥ 2, n (%) 4 (40) 16 (66.7) 7 (70) 0.28 Pathological diagnosis, n (%) 0.42 UC 10 (100) 22 (91.7) 10 (100) Non-UC 0 (0) 2 (8.3) 0 (0) Pathological T stage, n (%) 0.0011* 1 4 (40) 0 (0) 0 (0) 2 6 (60) 24 (100) 9 (90) 3 0 (0) 0 (0) 1 (10) Variant histology, n (%) 1 (10) 3 (12.5) 1 (10) 0.96 Urinary diversion, n (%) Ileal conduit 8 (80) Cutaneous ureterostomy 2 (20) Treatment details, n (%) Chemoradiotherapy 8 (33.3) Radiotherapy 13 (54.2) Systemic Chemotherapy 3 (12.5) Recurrence, n (%) 3 (30) 4 (16.7) 0 (0) 0.18 Death, n (%) 2 (20) 8 (33.3) 2 (20) 0.61 Follow-up period, months (IQR) 27 [17–41] 11 [4–21] 6 [ 1 – 20 ] 0.0086* ASA-PS, American Society of Anesthesiologists Physical Status; mFI-5, modified Frailty Index-5; COPD, chronic obstructive pulmonary disease; UC, Urothelial carcinoma; IQR, Interquartile range; n, population. *Statistically significant. [Insert Table 1 here] Next, we performed a logistic regression analysis to identify the factors associated with RARC selection (Table 2 ). Neither sex (OR, 0.68; p = 0.65) nor age (OR, 0.86; p = 0.24) was significantly associated with the decision to perform surgery. However, an mFI-5 score of ≥ 2 was associated with a lower likelihood of undergoing RARC (OR: 0.31, 95% CI: 0.07–1.38, p = 0.12). The sample size was small, preventing statistically significant findings; however, the OR for the mFI-5 was notably lower than that for age, indicating that frailty status is a more distinct factor for treatment allocation than chronological age in this cohort. Table 2 Univariable and multivariable logistic regression analysis to identify factors associated with the selection of RARC Parameter Univariable Multivariable OR (95% CI) p OR (95% CI) p Age 0.89 (0.71–1.11) 0.30 0.86 (0.67–1.11) 0.24 Sex, male 0.72 (0.15–3.44) 0.68 0.68 (0.12–3.75) 0.65 Female Reference Reference mFI-5 score ≥ 2 0.32 (0.074–1.37) 0.12 0.31 (0.068–1.38) 0.12 mFI-5 score < 2 Reference Reference RARC, robot-assisted radical cystectomy; mFI-5, modified Frailty Index-5; OR, odds ratio. CI: confidence interval Figure 1 shows the Kaplan–Meier survival curves for OS stratified by treatment group. During the follow-up period, deaths occurred in 2 (20%), 8 (33.3%), and 2 (20%) patients in the RARC, non-surgical treatment, and observation groups, respectively. The median OS was not reached in the RARC group, but was 29 months in the non-surgical treatment group. In the observation group, the median OS was estimated to be 34 months; however, this result should be interpreted cautiously owing to the significantly short follow-up duration. The log-rank test did not show a statistically significant difference among the three groups (p = 0.11); however, the RARC group showed a consistently higher survival rate than did the non-surgical treatment group. Cox proportional hazards regression analyses were subsequently performed to evaluate the association between the treatment modality and OS (Table 3 ). In the univariate analysis, using the RARC group as the reference, the non-surgical treatment group exhibited a notably high hazard of death (HR: 4.93; 95% CI: 0.97–24.95; p = 0.054). The observation group exhibited an HR higher than that of the RARC group (HR: 2.43; 95% CI: 0.34–17.35; p = 0.38). Table 3 Univariate and multivariate Cox proportional hazards regression analyses for overall survival Parameter Univariable Multivariable HR (95% CI) p HR (95% CI) p Age 0.98 (0.82–1.13) 0.75 0.99 (0.78–1.20) 0.94 RARC Reference Reference Non-surgical treatment 4.93 (0.97–24.95) 0.054 4.89 (0.95–25.04) 0.057 Observation 2.43 (0.34–17.35) 0.38 2.57 (0.23–28.65) 0.44 RARC, robot-assisted radical cystectomy; HR, hazard ratio; CI, confidence interval A multivariate Cox regression analysis adjusted for age was also conducted. Despite the limited number of events, the association between non-surgical treatment and increased mortality risk compared with RARC remained consistent (HR: 4.89; 95% CI: 0.95–25.04; p = 0.057). Finally, to assess the robustness of these findings, a sensitivity analysis was performed, excluding the observation group, to minimize the bias associated with a significantly shorter follow-up duration. In this sub-analysis (n = 34), the survival benefit of RARC compared with non-surgical treatment remained consistent (HR: 4.98; 95% CI: 0.96–25.68; p = 0.055). Figure 2 illustrates the Kaplan–Meier survival curves stratified by mFI-5 score (low: <2 vs. high: ≥2). The log-rank test revealed no statistically significant difference in the OS between the two groups (p = 0.64). This result indicated that in this cohort, OS outcomes were comparable between patients with high and low mFI-5 scores. Discussion The primary aim of this study was to elucidate the factors influencing treatment selection in octogenarians with bladder cancer who are candidates for radical cystectomy. Our findings suggest that frailty assessment using the mFI-5 rather than chronological age plays a significant role in determining surgical indications. Furthermore, patients who underwent RARC showed a trend toward improved survival compared with those who received non-surgical treatment. Collectively, these findings indicate that patient stratification based on mFI-5 is clinically useful and that RARC might remain a beneficial treatment option for carefully selected older patients (octogenarians). Traditionally, radical cystectomy is associated with substantial perioperative morbidity, necessitating careful patient selection [ 1 , 16 , 17 ]. Consequently, octogenarians who are more susceptible to frailty are often excluded from surgical candidacy [ 11 , 12 , 18 ]. However, the widespread adoption of robot-assisted surgery has reduced surgical invasiveness and contributed to the gradual expansion of surgical indications in this population [ 19 ]. Nevertheless, standardized criteria for patient selection remain undefined, and treatment decisions are frequently based on subjective clinical judgment. In this study, the RARC group (n = 10) experienced no perioperative mortality or severe complications (Clavien–Dindo grade ≥ Ⅲ). This favorable safety profile suggests that RARC is safe in octogenarians when patients are appropriately selected. Evidence suggests that biological age, rather than chronological age, is a more reliable indicator of physiological reserve and surgical risk [ 13 , 20 ]. We hypothesized that this distinction would be particularly pronounced in older patients, such as the octogenarians included in this study. Consistent with this hypothesis, our logistic regression analysis showed that the mFI-5 has a stronger association with surgical selection than chronological age. This finding suggests that in real-world clinical practice, physicians should prioritize physiological fitness, as reflected by frailty status, over chronological age in determining surgical eligibility. The mFI-5 integrates comorbidities and functional status into a simple scoring system, making it a practical and feasible tool for objective patient assessment. In an aging society, the use of such an objective risk stratification tool is essential to mitigate age-related bias and avoid undertreatment of physiologically fit older patients. In this study, patients who underwent RARC showed a trend toward improved survival, suggesting that radical surgery may offer a prognostic benefit to carefully selected octogenarians. In the observation group, the significantly shorter follow-up duration partly explained the apparently favorable survival outcomes, as many patients likely discontinued follow-up owing to rapid clinical deterioration. This imbalance highlights the influence of selection bias, including the healthy user effect, in the surgical cohort. Interestingly, OS did not differ significantly according to the mFI-5 score across the cohort. Higher frailty is generally associated with poorer survival outcomes; however, this seemingly counterintuitive result may reflect the effectiveness of risk-adapted treatment selection in our practice. Surgery-related morbidity and mortality are reduced by identifying frail patients (mFI-5 ≥ 2) and allocating them to less invasive treatment strategies. Summarily, these findings suggest that mFI-5-based patient selection could function as an effective framework for individualized, risk-adapted treatment decision making, rather than as a direct prognostic marker. This study had certain limitations. First, this was a single-center retrospective analysis with a relatively small sample size (n = 44), which limits its statistical power and generalizability. Second, an inherent selection bias existed in treatment allocation. However, because the primary objective of this study was to evaluate the clinical utility of the mFI-5 in real-world decision making, this bias reflects actual the clinical practice patterns rather than an experimental treatment framework. Third, the RARC group included four patients with high-risk T1 disease. Radical cystectomy is an established indication in this context; however, the inclusion of non-muscle-invasive bladder cancer might have contributed to the favorable survival outcomes observed in the surgical group. Finally, a significant imbalance in follow-up duration, particularly the shorter observation period in the non-surgical group due to early attrition, introduced the possibility of informative censoring, limiting the precision of long-term survival comparisons and warranting a cautious interpretation of these results. Conclusions Our study indicated that frailty status is a more critical determinant than chronological age in the decision-making process for conducting RARC in octogenarians as assessed using the mFI-5. Our findings suggest that appropriate patient stratification using the mFI-5 enables safe RARC implementation with favorable survival outcomes, highlighting that advanced age alone should not preclude potentially curative surgery in physiologically fit individuals. Further large-scale prospective studies are needed to validate the utility of the mFI-5 as a standardized tool for optimizing treatment strategies in this increasingly older population. Abbreviations BCG Bacilli Calmette-Guerin CI Confidence interval HR Hazard ratio OR Odds ratio OS Overall survival Declarations Ethics approval and consent to participate The protocol for this research was approved by a suitably constituted Ethics Committee of Jichi Medical University Hospital’s institution, and it conforms to the provisions of the Declaration of Helsinki. Approval No. A22-023. Written informed consent was obtained from all patients prior to their participation in the study. Consent for Publication N/A Availability of data and materials The dataset analyzed in this study is available from the corresponding author upon reasonable request. Competing interests All authors declare no conflict of interest. Funding N/A Authors’ contributions HH contributed to the study conception and design, data analysis and interpretation, and drafting of the first version of the manuscript. TS, MK, and ET contributed to the data acquisition and helped draft the manuscript. HK and TF supervised the study, helped draft the manuscript, and critically revised it for important intellectual content. All the authors have read and approved the final version of the manuscript. Acknowledgments We would like to thank Editage (www.editage.com) for assistance with English language editing. References Alfred Witjes J, Max Bruins H, Carrión A, Cathomas R, Compérat E, Efstathiou JA, et al. European Association of Urology Guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2023 guidelines. Eur Urol. 2024;85:17–31. Catto JWF, Khetrapal P, Ricciardi F, Ambler G, Williams NR, Al-Hammouri T, et al. Effect of robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy on 90-day morbidity and mortality among patients with bladder cancer: a randomized clinical trial. JAMA. 2022;327:2092–103. Khetrapal P, Catto JWF, Kelly JD. Robot-assisted versus open cystectomy in the RAZOR trial. Lancet. 2019;393:644–5. Parekh DJ, Reis IM, Castle EP, Gonzalgo ML, Woods ME, Svatek RS, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet. 2018;391:2525–36. Ploussard G, Shariat SF, Dragomir A, Kluth LA, Xylinas E, Masson-Lecomte A, et al. Conditional survival after radical cystectomy for bladder cancer: evidence for a patient changing risk profile over time. Eur Urol. 2014;66:361–70. Shariat SF, Karakiewicz PI, Palapattu GS, Amiel GE, Lotan Y, Rogers CG, et al. Nomograms provide improved accuracy for predicting survival after radical cystectomy. Clin Cancer Res. 2006;12:6663–76. Hampson A, Vincent A, Dasgupta P, Vasdev N. Radical cystectomy complications and perioperative mortality. BJU Int. 2019;124:3–4. Packiam VT, Pariser JJ. Association between perioperative morbidity and mortality after radical cystectomy: an opportunity to understand the complication snowball effect. Transl Androl Urol. 2019;8:S261–2. Mossanen M, Krasnow RE, Zlatev DV, Tan WS, Preston MA, Trinh QD, et al. Examining the relationship between complications and perioperative mortality following radical cystectomy: a population-based analysis. BJU Int. 2019;124:40–6. Koga F, Kihara K. Selective bladder preservation with curative intent for muscle-invasive bladder cancer: a contemporary review. Int J Urol. 2012;19:388–401. Duwe G, Wagner I, Banasiewicz KE, Frey LJ, Fischer ND, Bierlein J, et al. Radical cystectomy in patients aged < 80 years versus ≥ 80 years: analysis of preoperative geriatric assessment scores in predicting postoperative morbidity and mortality. World J Urol. 2024;42:552. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210:901–8. Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-Factor Modified Frailty Index Using American College of Surgeons NSQIP Data. J Am Coll Surg. 2018;226:173 – 81.e8. Agathis AZ, Wu J, Divino CM. New surgical frailty scoring tool: modified 4-factor functional frailty index. J Am Coll Surg. 2025;241:370–8. Araújo-Andrade L, Rocha-Neves JP, Duarte-Gamas L, Pereira-Neves A, Ribeiro H, Pereira-Macedo J, et al. Prognostic effect of the new 5-factor modified frailty index in patients undergoing carotid endarterectomy with regional anesthesia - a prospective cohort study. Int J Surg. 2020;80:27–34. Roghmann F, Trinh QD, Braun K, von Bodman C, Brock M, Noldus J, et al. Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy. Int J Urol. 2014;21:143–9. Yamashita S, Mashima N, Higuchi M, Matsumura N, Hagino K, Kikkawa K, et al. Modified 5-item frailty index score as prognostic marker after radical cystectomy in bladder cancer. Clin Genitourin Cancer. 2022;20:e210–6. Ethun CG, Bilen MA, Jani AB, Maithel SK, Ogan K, Master VA. Frailty and cancer: implications for oncology surgery, medical oncology, and radiation oncology. CA Cancer J Clin. 2017;67:362–77. Daneshmand S, Ahmadi H, Schuckman AK, Mitra AP, Cai J, Miranda G, et al. Enhanced recovery protocol after radical cystectomy for bladder cancer. J Urol. 2014;192:50–6. Voskamp MJH, Vermeer M, Molijn GJ, Cornel EB. The usefulness of the modified frailty index for muscle-invasive bladder cancer patients treated with radical cystectomy. Curr Urol. 2020;14:32–7. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9059441","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":608510039,"identity":"41aba0ea-40b9-48bf-baed-ba84fc08cd5c","order_by":0,"name":"Hayato Hoshina","email":"data:image/png;base64,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","orcid":"","institution":"Jichi Medical University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Hayato","middleName":"","lastName":"Hoshina","suffix":""},{"id":608510040,"identity":"02cf5fea-c070-4d41-92c9-c9f6a9c4e343","order_by":1,"name":"Toru Sugihara","email":"","orcid":"","institution":"Jichi Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Toru","middleName":"","lastName":"Sugihara","suffix":""},{"id":608510048,"identity":"806b8d1d-65a6-4c8e-b138-b33cd0ea2cd6","order_by":2,"name":"Masayuki Kurokawa","email":"","orcid":"","institution":"Jichi Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masayuki","middleName":"","lastName":"Kurokawa","suffix":""},{"id":608510051,"identity":"a9804be2-13a8-494f-8275-b2fa767fb391","order_by":3,"name":"Ei-ichiro Takaoka","email":"","orcid":"","institution":"Jichi Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ei-ichiro","middleName":"","lastName":"Takaoka","suffix":""},{"id":608510053,"identity":"2a244bdc-6801-4faa-839b-97035b6ac73f","order_by":4,"name":"Haruki Kume","email":"","orcid":"","institution":"The University of Tokyo","correspondingAuthor":false,"prefix":"","firstName":"Haruki","middleName":"","lastName":"Kume","suffix":""},{"id":608510054,"identity":"5ce95cc1-b5d0-4ef5-bf53-7d94c094ef90","order_by":5,"name":"Tetsuya Fujimura","email":"","orcid":"","institution":"Jichi Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tetsuya","middleName":"","lastName":"Fujimura","suffix":""}],"badges":[],"createdAt":"2026-03-07 15:23:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9059441/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9059441/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105563737,"identity":"9bf0c144-46f2-4a54-9389-e079a9a2357c","added_by":"auto","created_at":"2026-03-27 12:47:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":306421,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier survival curves for overall survival stratified by treatment group. The overall difference among the three groups was assessed using the log-rank test (p = 0.11).\u003c/p\u003e\n\u003cp\u003eExploratory pairwise comparisons showed a longer overall survival in the robot-assisted radical cystectomy (RARC) group than in the non-surgical treatment group (p = 0.038), whereas no difference was observed between the RARC and observation groups (p = 0.40).\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9059441/v1/b1ab5c64a13c609dfa062c37.jpg"},{"id":105150384,"identity":"b4b49466-8866-43aa-bd7b-aa34a91eb491","added_by":"auto","created_at":"2026-03-22 15:01:53","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":246664,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier survival curves stratified by modified Frailty Index-5 score (low: \u0026lt;2 vs. high: ≥2).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9059441/v1/ec910021d12175b36c189e70.jpg"},{"id":105569232,"identity":"a512fc5f-4e76-4cb3-8303-9c505291d4c1","added_by":"auto","created_at":"2026-03-27 13:11:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1308533,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9059441/v1/e24763e9-779e-4369-a4d4-11d86d948125.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of the Modified Frailty Index-5 on Treatment Selection and Prognosis in Octogenarians with Bladder Cancer Eligible for Radical Cystectomy: A Single-center, Retrospective Study ","fulltext":[{"header":"Background","content":"\u003cp\u003eRadical cystectomy remains the gold standard treatment for invasive or high-risk recurrent bladder cancer [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. With the widespread adoption of robot-assisted radical cystectomy (RARC), surgical indications have expanded owing to its reduced invasiveness compared with that via open surgery [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Nevertheless, radical cystectomy is associated with substantial morbidity and a reported 5-year survival rate of approximately 50% [\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Additionally, urinary diversion requirement can significantly affect patients\u0026rsquo; quality of life, including body image and long-term urinary management. Therefore, careful patient selection is essential to balance the oncological benefits with the postoperative risk [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn rapidly aging societies, the incidence of invasive bladder cancer among octogenarians is steadily increasing, presenting unique therapeutic challenges [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Surgery is often considered the optimal approach for local disease control; however, older patients face competing risks, including cognitive impairment and physical frailty [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These factors increase the likelihood of postoperative complications, difficulties in stoma management, and a decline in activities of daily living. However, decisions regarding surgical eligibility in this population lack standardized criteria and rely heavily on subjective clinical judgments or patient preference [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and objective and practical frailty assessment tools are needed to address this uncertainty. Although use of the modified Frailty Index-5 (mFI-5) is particularly attractive owing to its simplicity and reliance on routinely available clinical information [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], limited data exist regarding its role in guiding real-world treatment selection in extremely elderly individuals. Therefore, in this study, we aimed to retrospectively evaluate the impact of mFI-5 status on treatment decision making in octogenarians with bladder cancer and to assess overall survival (OS) in patients selected for RARC based on this stratification.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eBetween January 2018 and December 2025, 146 patients aged\u0026thinsp;\u0026ge;\u0026thinsp;80 years underwent transurethral resection of a bladder tumor (TURBT) at Jichi Medical University Hospital. The study population comprised 44 patients deemed candidates for radical cystectomy during this period or who underwent TURBT at another institution during the same period and were subsequently referred to our hospital with the same diagnosis. We included patients (1) diagnosed with muscle-invasive bladder cancer (\u0026ge;\u0026thinsp;pathological tumor (pT) 2) based on pathological findings, (2) deemed suitable for cystectomy owing to non-response to Bacilli Calmette-Guerin (BCG) therapy, and (3) diagnosed with pT1 variant bladder cancer [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. We excluded cases involving distant metastasis or non-cancerous pathological diagnoses (malignant lymphoma). This was a single-center, retrospective study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Jichi Medical University Hospital (approval no. A22-023). Written informed consent was obtained from all participants before their inclusion in the study.\u003c/p\u003e\n\u003ch3\u003eData Collections\u003c/h3\u003e\n\u003cp\u003eThe patients were classified into three groups based on the documented treatment history in their medical records: radical cystectomy, non-surgical treatment, and observation (those who did not undergo treatment after TURBT) groups. All patients in the radical cystectomy group underwent RARC using the da Vinci System (Intuitive Surgical Inc., Sunnyvale, CA, USA). Patients in the non-surgical treatment group received chemoradiotherapy, radiotherapy, or chemotherapy alone. The mFI-5 score was calculated based on the presence of any of the following comorbidities at the time of surgery: history of congestive heart failure within 30 days before surgery; presence of insulin-dependent or non-insulin-dependent diabetes; history of long-term obstructive pulmonary disease or pneumonia; dependence on complete or partial functional health status; and presence of hypertension requiring medication. Based on previous findings, mFI-5 was classified as \u0026ge;\u0026thinsp;2 points (high group) or \u0026lt;\u0026thinsp;2 points (low group) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eEnd Points\u003c/h3\u003e\n\u003cp\u003eFirst, we evaluated the factors influencing surgical treatment selection, focusing on the impact of mFI-5. Second, we assessed OS to explore the association between the treatment strategy and prognosis in this cohort.\u003c/p\u003e\n\u003ch3\u003eStatistics Analysis\u003c/h3\u003e\n\u003cp\u003eFor univariate analysis, categorical and continuous data were compared using the chi-squared and Mann\u0026ndash;Whitney U test, respectively. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with RARC selection. The variables included in the model were age, sex, and the mFI-5, dichotomized as \u0026lt;\u0026thinsp;2 versus \u0026ge;\u0026thinsp;2. The results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).\u003c/p\u003e \u003cp\u003eOS was estimated using the Kaplan\u0026ndash;Meier method, and differences between groups were assessed using the log-rank test. To explore the association between treatment strategy and prognosis, we performed Cox proportional hazards regression analysis and calculated hazard ratios (HRs) with 95% CIs. Given the limited number of events, the primary variables of the Cox regression model were the treatment modality and age. Other clinical variables, including mFI-5, were not included in the multivariable Cox model to avoid overfitting owing to the limited number of events. For sensitivity analysis, we excluded patients under observation without active treatment, and reanalyzed survival outcomes by comparing the radical cystectomy and non-surgical treatment groups. We also used the Kaplan\u0026ndash;Meier method to evaluate OS in the high- and low-risk groups based on the mFI-5 scores.\u003c/p\u003e \u003cp\u003eAll statistical analyses were performed using JMP version 17 (SAS Institute, Cary, NC, USA), and statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows a summary of the patient characteristics. Overall, 44 patients were enrolled and stratified into the RARC (n\u0026thinsp;=\u0026thinsp;10), non-surgical treatment (n\u0026thinsp;=\u0026thinsp;24), and observation (n\u0026thinsp;=\u0026thinsp;10) groups. The median age was significantly higher in the observation group (87 years) than in the RARC (82 years) and non-surgical treatment (81 years) groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Regarding frailty status, there were no statistically significant differences in the individual mFI-5 components or total scores among the three groups. However, the proportion of patients with an mFI-5 score\u0026thinsp;\u0026ge;\u0026thinsp;2 was lowest in the RARC group (40%), compared with those in the non-surgical treatment (66.7%) and observation (70%) groups. This difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.28). In the RARC group, four patients (40%) had pathological T1 disease. Indications for RARC included variant histology (n\u0026thinsp;=\u0026thinsp;1) and BCG failure (n\u0026thinsp;=\u0026thinsp;3). The breakdown of the non-surgical treatment group was as follows: chemoradiotherapy, radiotherapy, and chemotherapy alone in 8, 13, and 3 cases, respectively. Notably, the median follow-up duration differed significantly between the groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with the longest in the RARC group (27 months) and shortest in the observation group (6 months).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics across all populations (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRARC group, n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-surgical treatment group, n\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eObservation group, n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (79.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 [80\u0026ndash;83]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 [81\u0026ndash;84]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87 [83\u0026ndash;91]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0056*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index, (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.4 [22.6\u0026ndash;27.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.9 [19.9\u0026ndash;26.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.5 [20.6\u0026ndash;23.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA-PS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComponent mFI-5, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of congestive heart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of COPD or pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotally or partially dependent functional health status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension requiring medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (79.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFI-5 score, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (58.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFI-5\u0026thinsp;\u0026ge;\u0026thinsp;2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological diagnosis,\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (91.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-UC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological T stage,\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0011*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariant histology, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary diversion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCutaneous ureterostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment details, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemoradiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystemic Chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up period, months (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 [17\u0026ndash;41]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 [4\u0026ndash;21]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0086*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eASA-PS, American Society of Anesthesiologists Physical Status; mFI-5, modified Frailty Index-5; COPD, chronic obstructive pulmonary disease; UC, Urothelial carcinoma; IQR, Interquartile range; n, population.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e[Insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003ehere]\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNext, we performed a logistic regression analysis to identify the factors associated with RARC selection (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Neither sex (OR, 0.68; p\u0026thinsp;=\u0026thinsp;0.65) nor age (OR, 0.86; p\u0026thinsp;=\u0026thinsp;0.24) was significantly associated with the decision to perform surgery. However, an mFI-5 score of \u0026ge;\u0026thinsp;2 was associated with a lower likelihood of undergoing RARC (OR: 0.31, 95% CI: 0.07\u0026ndash;1.38, p\u0026thinsp;=\u0026thinsp;0.12). The sample size was small, preventing statistically significant findings; however, the OR for the mFI-5 was notably lower than that for age, indicating that frailty status is a more distinct factor for treatment allocation than chronological age in this cohort.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariable and multivariable logistic regression analysis to identify factors associated with the selection of RARC\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariable\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.89 (0.71\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86 (0.67\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.72 (0.15\u0026ndash;3.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.68 (0.12\u0026ndash;3.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFI-5 score\u0026thinsp;\u0026ge;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.32 (0.074\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.31 (0.068\u0026ndash;1.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFI-5 score\u0026thinsp;\u0026lt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRARC, robot-assisted radical cystectomy; mFI-5, modified Frailty Index-5; OR, odds ratio.\u003c/p\u003e \u003cp\u003eCI: confidence interval\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the Kaplan\u0026ndash;Meier survival curves for OS stratified by treatment group. During the follow-up period, deaths occurred in 2 (20%), 8 (33.3%), and 2 (20%) patients in the RARC, non-surgical treatment, and observation groups, respectively. The median OS was not reached in the RARC group, but was 29 months in the non-surgical treatment group. In the observation group, the median OS was estimated to be 34 months; however, this result should be interpreted cautiously owing to the significantly short follow-up duration. The log-rank test did not show a statistically significant difference among the three groups (p\u0026thinsp;=\u0026thinsp;0.11); however, the RARC group showed a consistently higher survival rate than did the non-surgical treatment group.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCox proportional hazards regression analyses were subsequently performed to evaluate the association between the treatment modality and OS (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the univariate analysis, using the RARC group as the reference, the non-surgical treatment group exhibited a notably high hazard of death (HR: 4.93; 95% CI: 0.97\u0026ndash;24.95; p\u0026thinsp;=\u0026thinsp;0.054). The observation group exhibited an HR higher than that of the RARC group (HR: 2.43; 95% CI: 0.34\u0026ndash;17.35; p\u0026thinsp;=\u0026thinsp;0.38).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate and multivariate Cox proportional hazards regression analyses for overall survival\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariable\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98 (0.82\u0026ndash;1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99 (0.78\u0026ndash;1.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRARC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-surgical treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.93 (0.97\u0026ndash;24.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.89 (0.95\u0026ndash;25.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.43 (0.34\u0026ndash;17.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.57 (0.23\u0026ndash;28.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRARC, robot-assisted radical cystectomy; HR, hazard ratio; CI, confidence interval\u003c/p\u003e \u003cp\u003eA multivariate Cox regression analysis adjusted for age was also conducted. Despite the limited number of events, the association between non-surgical treatment and increased mortality risk compared with RARC remained consistent (HR: 4.89; 95% CI: 0.95\u0026ndash;25.04; p\u0026thinsp;=\u0026thinsp;0.057). Finally, to assess the robustness of these findings, a sensitivity analysis was performed, excluding the observation group, to minimize the bias associated with a significantly shorter follow-up duration. In this sub-analysis (n\u0026thinsp;=\u0026thinsp;34), the survival benefit of RARC compared with non-surgical treatment remained consistent (HR: 4.98; 95% CI: 0.96\u0026ndash;25.68; p\u0026thinsp;=\u0026thinsp;0.055).\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the Kaplan\u0026ndash;Meier survival curves stratified by mFI-5 score (low: \u0026lt;2 vs. high: \u0026ge;2). The log-rank test revealed no statistically significant difference in the OS between the two groups (p\u0026thinsp;=\u0026thinsp;0.64). This result indicated that in this cohort, OS outcomes were comparable between patients with high and low mFI-5 scores.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary aim of this study was to elucidate the factors influencing treatment selection in octogenarians with bladder cancer who are candidates for radical cystectomy. Our findings suggest that frailty assessment using the mFI-5 rather than chronological age plays a significant role in determining surgical indications. Furthermore, patients who underwent RARC showed a trend toward improved survival compared with those who received non-surgical treatment. Collectively, these findings indicate that patient stratification based on mFI-5 is clinically useful and that RARC might remain a beneficial treatment option for carefully selected older patients (octogenarians).\u003c/p\u003e \u003cp\u003eTraditionally, radical cystectomy is associated with substantial perioperative morbidity, necessitating careful patient selection [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Consequently, octogenarians who are more susceptible to frailty are often excluded from surgical candidacy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the widespread adoption of robot-assisted surgery has reduced surgical invasiveness and contributed to the gradual expansion of surgical indications in this population [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Nevertheless, standardized criteria for patient selection remain undefined, and treatment decisions are frequently based on subjective clinical judgment. In this study, the RARC group (n\u0026thinsp;=\u0026thinsp;10) experienced no perioperative mortality or severe complications (Clavien\u0026ndash;Dindo grade \u0026ge; Ⅲ). This favorable safety profile suggests that RARC is safe in octogenarians when patients are appropriately selected.\u003c/p\u003e \u003cp\u003eEvidence suggests that biological age, rather than chronological age, is a more reliable indicator of physiological reserve and surgical risk [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. We hypothesized that this distinction would be particularly pronounced in older patients, such as the octogenarians included in this study. Consistent with this hypothesis, our logistic regression analysis showed that the mFI-5 has a stronger association with surgical selection than chronological age. This finding suggests that in real-world clinical practice, physicians should prioritize physiological fitness, as reflected by frailty status, over chronological age in determining surgical eligibility. The mFI-5 integrates comorbidities and functional status into a simple scoring system, making it a practical and feasible tool for objective patient assessment. In an aging society, the use of such an objective risk stratification tool is essential to mitigate age-related bias and avoid undertreatment of physiologically fit older patients.\u003c/p\u003e \u003cp\u003eIn this study, patients who underwent RARC showed a trend toward improved survival, suggesting that radical surgery may offer a prognostic benefit to carefully selected octogenarians. In the observation group, the significantly shorter follow-up duration partly explained the apparently favorable survival outcomes, as many patients likely discontinued follow-up owing to rapid clinical deterioration. This imbalance highlights the influence of selection bias, including the healthy user effect, in the surgical cohort. Interestingly, OS did not differ significantly according to the mFI-5 score across the cohort. Higher frailty is generally associated with poorer survival outcomes; however, this seemingly counterintuitive result may reflect the effectiveness of risk-adapted treatment selection in our practice. Surgery-related morbidity and mortality are reduced by identifying frail patients (mFI-5\u0026thinsp;\u0026ge;\u0026thinsp;2) and allocating them to less invasive treatment strategies. Summarily, these findings suggest that mFI-5-based patient selection could function as an effective framework for individualized, risk-adapted treatment decision making, rather than as a direct prognostic marker.\u003c/p\u003e \u003cp\u003eThis study had certain limitations. First, this was a single-center retrospective analysis with a relatively small sample size (n\u0026thinsp;=\u0026thinsp;44), which limits its statistical power and generalizability. Second, an inherent selection bias existed in treatment allocation. However, because the primary objective of this study was to evaluate the clinical utility of the mFI-5 in real-world decision making, this bias reflects actual the clinical practice patterns rather than an experimental treatment framework. Third, the RARC group included four patients with high-risk T1 disease. Radical cystectomy is an established indication in this context; however, the inclusion of non-muscle-invasive bladder cancer might have contributed to the favorable survival outcomes observed in the surgical group. Finally, a significant imbalance in follow-up duration, particularly the shorter observation period in the non-surgical group due to early attrition, introduced the possibility of informative censoring, limiting the precision of long-term survival comparisons and warranting a cautious interpretation of these results.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study indicated that frailty status is a more critical determinant than chronological age in the decision-making process for conducting RARC in octogenarians as assessed using the mFI-5. Our findings suggest that appropriate patient stratification using the mFI-5 enables safe RARC implementation with favorable survival outcomes, highlighting that advanced age alone should not preclude potentially curative surgery in physiologically fit individuals. Further large-scale prospective studies are needed to validate the utility of the mFI-5 as a standardized tool for optimizing treatment strategies in this increasingly older population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBCG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Bacilli Calmette-Guerin\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Confidence interval\u003c/p\u003e\n\u003cp\u003eHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hazard ratio\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Odds ratio\u003c/p\u003e\n\u003cp\u003eOS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Overall survival\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol for this research was approved by a suitably constituted Ethics Committee of Jichi Medical University Hospital\u0026rsquo;s institution, and it conforms to the provisions of the Declaration of Helsinki. Approval No. A22-023. Written informed consent was obtained from all patients prior to their participation in the study.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for Publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset analyzed in this study is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no conflict of interest.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHH contributed to the study conception and design, data analysis and interpretation, and drafting of the first version of the manuscript. TS, MK, and ET contributed to the data acquisition and helped draft the manuscript. HK and TF supervised the study, helped draft the manuscript, and critically revised it for important intellectual content. All the authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (www.editage.com) for assistance with English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlfred Witjes J, Max Bruins H, Carri\u0026oacute;n A, Cathomas R, Comp\u0026eacute;rat E, Efstathiou JA, et al. European Association of Urology Guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2023 guidelines. Eur Urol. 2024;85:17\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCatto JWF, Khetrapal P, Ricciardi F, Ambler G, Williams NR, Al-Hammouri T, et al. Effect of robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy on 90-day morbidity and mortality among patients with bladder cancer: a randomized clinical trial. JAMA. 2022;327:2092\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhetrapal P, Catto JWF, Kelly JD. Robot-assisted versus open cystectomy in the RAZOR trial. Lancet. 2019;393:644\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParekh DJ, Reis IM, Castle EP, Gonzalgo ML, Woods ME, Svatek RS, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet. 2018;391:2525\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePloussard G, Shariat SF, Dragomir A, Kluth LA, Xylinas E, Masson-Lecomte A, et al. Conditional survival after radical cystectomy for bladder cancer: evidence for a patient changing risk profile over time. Eur Urol. 2014;66:361\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShariat SF, Karakiewicz PI, Palapattu GS, Amiel GE, Lotan Y, Rogers CG, et al. Nomograms provide improved accuracy for predicting survival after radical cystectomy. Clin Cancer Res. 2006;12:6663\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHampson A, Vincent A, Dasgupta P, Vasdev N. Radical cystectomy complications and perioperative mortality. BJU Int. 2019;124:3\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePackiam VT, Pariser JJ. Association between perioperative morbidity and mortality after radical cystectomy: an opportunity to understand the complication snowball effect. Transl Androl Urol. 2019;8:S261\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMossanen M, Krasnow RE, Zlatev DV, Tan WS, Preston MA, Trinh QD, et al. Examining the relationship between complications and perioperative mortality following radical cystectomy: a population-based analysis. BJU Int. 2019;124:40\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoga F, Kihara K. Selective bladder preservation with curative intent for muscle-invasive bladder cancer: a contemporary review. Int J Urol. 2012;19:388\u0026ndash;401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuwe G, Wagner I, Banasiewicz KE, Frey LJ, Fischer ND, Bierlein J, et al. Radical cystectomy in patients aged\u0026thinsp;\u0026lt;\u0026thinsp;80 years versus \u0026ge;\u0026thinsp;80 years: analysis of preoperative geriatric assessment scores in predicting postoperative morbidity and mortality. World J Urol. 2024;42:552.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210:901\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-Factor Modified Frailty Index Using American College of Surgeons NSQIP Data. J Am Coll Surg. 2018;226:173\u0026thinsp;\u0026ndash;\u0026thinsp;81.e8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgathis AZ, Wu J, Divino CM. New surgical frailty scoring tool: modified 4-factor functional frailty index. J Am Coll Surg. 2025;241:370\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAra\u0026uacute;jo-Andrade L, Rocha-Neves JP, Duarte-Gamas L, Pereira-Neves A, Ribeiro H, Pereira-Macedo J, et al. Prognostic effect of the new 5-factor modified frailty index in patients undergoing carotid endarterectomy with regional anesthesia - a prospective cohort study. Int J Surg. 2020;80:27\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoghmann F, Trinh QD, Braun K, von Bodman C, Brock M, Noldus J, et al. Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy. Int J Urol. 2014;21:143\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamashita S, Mashima N, Higuchi M, Matsumura N, Hagino K, Kikkawa K, et al. Modified 5-item frailty index score as prognostic marker after radical cystectomy in bladder cancer. Clin Genitourin Cancer. 2022;20:e210\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEthun CG, Bilen MA, Jani AB, Maithel SK, Ogan K, Master VA. Frailty and cancer: implications for oncology surgery, medical oncology, and radiation oncology. CA Cancer J Clin. 2017;67:362\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaneshmand S, Ahmadi H, Schuckman AK, Mitra AP, Cai J, Miranda G, et al. Enhanced recovery protocol after radical cystectomy for bladder cancer. J Urol. 2014;192:50\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVoskamp MJH, Vermeer M, Molijn GJ, Cornel EB. The usefulness of the modified frailty index for muscle-invasive bladder cancer patients treated with radical cystectomy. Curr Urol. 2020;14:32\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bladder cancer, mFI-5, Octogenarians, RARC, Robot surgery","lastPublishedDoi":"10.21203/rs.3.rs-9059441/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9059441/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDeveloping treatment strategies for bladder cancer in octogenarians remains challenging owing to concerns regarding surgical invasiveness and the risk of undertreatment. We aimed to evaluate the effect of the modified Frailty Index-5 score on treatment selection and prognosis in this population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed 44 patients with bladder cancer aged\u0026thinsp;\u0026ge;\u0026thinsp;80 years who were candidates for radical cystectomy. The patients were stratified into three groups: robot-assisted radical cystectomy (n\u0026thinsp;=\u0026thinsp;10), non-surgical treatment (n\u0026thinsp;=\u0026thinsp;24), and observation (n\u0026thinsp;=\u0026thinsp;10).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMultivariate analysis revealed that compared with chronological age or sex, surgical selection was strongly influenced by the modified Frailty Index-5 status (odds ratio 0.31), suggesting that frailty assessment plays a crucial role in clinical decision making. Overall survival did not differ significantly among the groups (p\u0026thinsp;=\u0026thinsp;0.11); however, the robot-assisted radical cystectomy group showed a trend toward improved survival compared with the non-surgical treatment (hazard ratio [HR] 4.93; p\u0026thinsp;=\u0026thinsp;0.054) and observation (HR 2.43; p\u0026thinsp;=\u0026thinsp;0.38) groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eRobot-assisted radical cystectomy appears to be a safe and feasible treatment option for carefully selected octogenarian patients. The modified Frailty Index-5 may serve as a practical and objective tool to support treatment decision making, helping avoid undue risk aversion based solely on chronological age.\u003c/p\u003e","manuscriptTitle":"Impact of the Modified Frailty Index-5 on Treatment Selection and Prognosis in Octogenarians with Bladder Cancer Eligible for Radical Cystectomy: A Single-center, Retrospective Study ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-22 15:01:48","doi":"10.21203/rs.3.rs-9059441/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-30T20:28:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-23T02:36:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106829641667020579450919671508935282386","date":"2026-03-21T11:29:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T22:21:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62870420980215883882106507052850567637","date":"2026-03-18T22:13:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T16:16:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286902648419386984625151446744890511536","date":"2026-03-18T16:00:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-18T11:31:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-11T05:28:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-10T05:15:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-10T05:14:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2026-03-07T15:10:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"edd32b9c-ab87-4664-98c4-ed8f38877607","owner":[],"postedDate":"March 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T17:23:43+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-22 15:01:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9059441","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9059441","identity":"rs-9059441","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}