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

PURPOSE: Chronological age influences selection for radical cystectomy in bladder cancer, yet biological vulnerability may be more informative. We assessed perioperative outcomes and overall survival after robot-assisted radical cystectomy (RARC) and developed a pragmatic age–Eastern Cooperative Oncology Group (ECOG) risk score. METHODS: Consecutive RARC patients (August 2013–December 2024) were analyzed retrospectively and grouped by age (< 75, 75–79, 80–84, ≥ 85 years). Ninety-day complications were graded by Clavien–Dindo classification. Overall survival (OS) was estimated by Kaplan–Meier methods. An age threshold for overall mortality was derived by receiver operating characteristic analysis (Youden index). The risk score assigned one point each for age above the cut-off and ECOG performance status ≥ 2. Cox regression adjusted for Charlson Comorbidity Index and pathological T stage. RESULTS: Among 171 patients, length of stay and overall complications did not differ statistically across age strata, although comparisons are limited by selection and the small ≥ 85 subgroup. OS differed by age cohort (p = 0.00013) with an optimal age threshold of 76.5 years (p < 0.0001). ECOG ≥ 2 predicted worse survival (p < 0.0001), and the score separated 1, 2 and 3 score groups (p < 0.0001). On multivariable analysis, age > 76.5 years remained independently associated with worse overall survival (hazard ratio 2.72, 95% confidence interval 1.58–4.68; p < 0.001). CONCLUSION: RARC is feasible across advanced age strata in selected patients, but survival varies substantially. A simple age threshold plus ECOG performance status may aid counseling and perioperative planning and warrants external validation.