Organ-Sparing Strategies in Muscle-Invasive Bladder Cancer

Radical cystectomy (RC) is the treatment of choice and is strongly recommended for patients with pT2-4aN0M0 bladder cancer in both the European Association of Urology (EAU) and American Urological Association (AUA) muscle-invasive bladder cancer (MIBC) guidelines. RC is a challenging operation, with significant perioperative and postoperative morbidity and mortality, having short-term complication rates between 14.4% and 21.7%, and long-term oncological survival rates ranging from 60% after 5 years to 43% after 10 years. The impact on quality of life (QoL) in patients after treatment for bladder cancer is significantly worse than in other pelvic cancers. Although RC is strongly recommended as the gold standard, there is a need for bladder-sparing options in MIBC. Attempts to improve mortality and morbidity rates after RC have been made by implementing Enhanced Recovery After Surgery (ERAS), robot-assisted RC, and sexual function-preserving techniques. None of these significantly improves QoL or functional outcome. Because of the invasiveness of RC, other therapeutic options have been evaluated. Transurethral resection of the bladder tumor (TURB) plays an important role in the diagnostic evaluation of MIBC and has also been reviewed as a curative option, although the oncological results appear inferior to RC. Furthermore, improved radiotherapy (RT) and widely used chemotherapy, both as monotherapeutic options in bladder cancer, are not as effective as radical surgery, with lower survival rates. Trimodality treatment (TMT) in bladder cancer combines TURB with chemotherapy and RT. The goal of TMT is preserving the bladder and QoL without compromising oncological outcome. A 2018 review showed no difference in overall survival rates between RC and TMT (30.9% vs 35.1%), with lower survival rates after RC than TMT in the first year of follow-up, probably due to higher postoperative mortality. For a selected group of patients, TMT is to be recommended, and it is the most favorable option out of the organ-sparing strategies in MIBC.