Advancing Perioperative Treatment Options for Localized Muscle-Invasive Bladder Cancer: A Step Forward

Muscle-invasive bladder cancer (MIBC) is an aggressive disease, with substantial recurrence risk after radical cystectomy and pelvic lymph node dissection alone. In cisplatin-eligible patients, administration of neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy has been shown to improve overall survival (OS) and has become the standard of care. Nevertheless, approximately 40%-50% of patients will still experience disease recurrence after curative-intent treatment. Moreover, a significant proportion of patients with MIBC are ineligible for cisplatin and represent a challenging clinical scenario. In recent years, different strategies aiming to improve patient outcomes by incorporating immune checkpoint inhibitors in the treatment paradigm were explored. Two key management approaches emerged: neoadjuvant chemotherapy with risk-adapted adjuvant immunotherapy and universal perioperative immunotherapy-based treatment. We review the rationale, current evidence, challenges, and future directions for the perioperative management of muscle-invasive urothelial carcinoma.