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Introduction: Patients aged ≥80 years undergo radical cystectomy (RC) significantly less frequently than younger patients, largely due to concerns about perioperative morbidity and mortality risk. We assessed whether chronological age independently predicts short-term mortality and morbidity after RC when comorbidity burden and physiological fitness are balanced.

Method: We retrospectively analyzed 879 patients undergoing open RC (2015–2024) at a high-volume center. Octogenarians (80–89 years) were compared with patients <80 years. Propensity score matching (1:1 nearest neighbor; caliper 0.2 SD) balanced sex, ASA, Charlson Comorbidity Index, preoperative GFR, and BMI. Primary endpoints were 30- and 90-day mortality; secondary endpoints were major complications (Clavien–Dindo ≥IIIb) and 30-/90-day readmission. Multivariable logistic regression in the matched cohort assessed independent predictors.

Results: Among 879 patients, 114 (13%) were octogenarians. In the unmatched cohort, octogenarians had higher 30-day (6.1% vs. 1.4%; p=0.003) and 90-day mortality (10.5% vs. 3.9%; p=0.004). After matching (n=202), mortality rates were no longer significantly different between groups (30-day: 5.9% vs. 1.0%, p=0.124; 90-day: 9.9% vs. 4.0%, p=0.166), despite remaining numerically higher in octogenarians. Major complications and readmissions were comparable between matched groups. In multivariable regression analysis, age ≥80 years was not an independent predictor of adverse outcomes, whereas ASA ≥3 independently predicted major complications.

Conclusion: When comorbidity and physiological status are balanced, well-selected octogenarians can achieve short-term outcomes comparable to younger patients after RC. Chronological age alone should not preclude surgery; individualized risk assessment and treatment in experienced high-volume centers are essential.