New insights and emerging approaches in bladder-sparing treatment for muscle-invasive bladder cancer

Muscle-invasive bladder cancer (MIBC) poses significant challenges, traditionally treated with radical cystectomy, a procedure with considerable morbidity and impact on quality of life. Bladder-sparing approaches aim to preserve the bladder while maintaining oncological efficacy. This review explores emerging perspectives in bladder-sparing strategies for MIBC, focusing on patient selection criteria, molecular characterization, non-invasive treatment response assessment, systemic therapies, radiation techniques, and the role of intravesical devices.

A comprehensive narrative review provides insights into novel perspectives in bladder-sparing strategies for treating MIBC.

Patient selection criteria for bladder preservation remain challenging. While the traditional approach focuses on selecting candidates with MIBC with fewer clinicopathological risk characteristics, some studies suggest that histological variants and the presence of hydronephrosis may not be absolute exclusion criteria. Molecular classification data shows promise but lacks sufficient evidence, while immune cell infiltration may provide insights into potential treatment response. MRI and radiomics offer the potential for non-invasive treatment response assessment. Ongoing trials investigate new systemic therapies, radiation therapy approaches, and the role of intravesical devices in bladder preservation, with some preliminary data appearing promising.

Bladder-sparing strategies for MIBC are currently experiencing substantial evolution. Achieving optimal patient selection may entail the integration of clinical, radiological, histopathological, and molecular data. It is likely that shortly, multimodal approaches incorporating neoadjuvant systemic therapy, radiotherapy, intravesical devices, and possibly maintenance or adjuvant regimens guided by biomarker-driven strategies will become standard practice.