Elderly patients often present with increased comorbidities and frailty, which can limit their ability to undergo invasive surgical procedures. As a result, evidence-based recommendations for managing muscle-invasive bladder cancer (MIBC) in this population remain unclear. This systematic review and meta-analysis aim to evaluate the outcomes of radical cystectomy (RC) versus trimodal therapy (TMT) in elderly MIBC patients.

PubMed, Embase, Web of science, and Cochrane Library databases were searched. Clinical studies or retrospective studies with propensity score matching (PSM) or multivariate analysis were included if evaluating the treatments of interest in MIBC patients aged above 60; the assessment include prognostic risk factors and survival outcomes between TMT and RC.

Ten studies with 14,795 patients were retrieved. In patients aged 60-69, TMT had significant risk in the overall survival (HR= 1.60; 95% CI= 1.02-2.49) and cancer specific survival (HR= 1.59; 95% CI= 1.01-2.51), whereas above 70 had no difference. As for risk factors, clinical T2 (HR= 1.54; 95% CI= 1.24-1.88) and T3 (HR= 1.59; 95% CI= 1.18-2.14) stage have significantly poor prognosis in the treatment of TMT. Radiation dose above 60 Gray and Charlson Comorbidity Index (CCI) have no impact on the efficiency of treatment.

RC is recommended for MIBC in patients aged 60-69 and clinical T2 or T3 stage, while TMT is no inferior in patients aged above 70. Therefore, shared decision making with considering above risk factors and characteristics is recommended for the application of TMT or RC as anti-cancer strategies for the elderly MIBC patients.