New Bladder Preservation Strategies in Urothelial Carcinoma of the Bladder

17 500 persons receive a new diagnosis of urothelial carcinoma of the bladder in Germany each year. Radical cystectomy is performed for muscle-invasive and for non-muscle-invasive, recurrent, high-risk tumors. Because this procedure carries a perioperative complication rate of 30-40% and impairs the patients' quality of life, options have been developed for intravesical and systemic bladder-preserving treatment.

This review is based on pertinent publications (up to July 2024) on bladder-preserving treatment methods that were retrieved by a selective search in the PubMed, Web of Science, and Cochrane Library databases.

Multiple clinical phase II-III trials and observational studies are available. Carefully selected patients with recurrent, non-muscle-invasive, high-risk urothelial carcinoma received bladder-preserving treatment of the following kinds: intravesical chemotherapy with or without hyperthermia (52-65% progressionfree at 2-3 years); drug-coated carrier systems (complete remission, 50-83%); viral gene therapy (complete remission, 53%); systemic immunotherapy with checkpoint inhibitors (19-44% recurrence-free at 1 year). The rate of bladder preservation was 49-100%. No worsening of overall survival was observed. Treatments for muscle-invasive urothelial carcinoma included neoadjuvant chemotherapy followed by frequent follow-up, radical transurethral tumor resection, partial cystectomy, and trimodal radiochemotherapy (TMRT). Only TMRT yielded comparable long-term oncological results to those of cystectomy, with a 74% rate of freedom from metastases and an overall survival rate of 73%. Any type of bladder-preserving treatment requires meticulous long-term urooncological follow-up, with repeated cystoscopies, bladder biopsies, urine cytologies, and multiparametric bladder MRI.

Bladder-preserving treatments should be considered part of the therapeutic armamentarium and should be critically discussed in an interdisciplinary setting.