Bladder preservation: optimizing radiotherapy and integrated treatment strategies

While radical cystectomy (RC) remains the standard of care for muscle-invasive transitional cell carcinoma of the bladder, a series of single-institution and cooperative-group trials with a long-term follow-up have shown that combined modality therapy for bladder preservation can provide selected patients with an excellent chance for long-term survival with an intact, functioning bladder. Strategies for preserving the bladder have developed over the past 20 years, with continued refinements in radiation therapy, chemotherapy and patient selection. The hallmarks of modern bladder-preserving therapy include: (i) careful patient selection; (ii) combined therapy with maximum transurethral resection of bladder tumour, radiation and concurrent chemotherapy; (iii) cystoscopic assessment of the response to therapy with prompt salvage cystectomy for nonresponders; (iv) careful follow-up with cystoscopic surveillance and prompt cystectomy for invasive recurrence. Contemporary bladder-preserving approaches in patients with clinically staged muscle-invasive bladder cancer can achieve complete response rates of 60-85%, 5-year survival rates of 50-60%, and survival rates with an intact bladder of 40-45%. Although there are no randomized studies comparing RC with combined therapies for bladder preservation, long-term data show that overall and disease-specific survival rates in contemporary RC series of clinically staged patients with T2-T4a bladder cancer are comparable to those of bladder-preserving protocols. Thus, combined modality therapy for bladder preservation has become a safe, tested and effective alternative to RC in selected patients with muscle-invasive bladder cancer who desire to keep their bladders. Future work will continue to refine the bladder-preserving approach to improve survival and local control.