Advances in the management of localized bladder cancers

Bladder cancer remains a substantial global health burden. Localized, non-metastatic bladder cancer encompasses a spectrum from non-muscle-invasive bladder cancer (NMIBC) to muscle-invasive bladder cancer (MIBC). Advances in risk stratification, biomarker discovery and therapeutic innovation are reshaping the management of localized bladder cancers. Regarding NMIBC, enhanced cystoscopy techniques, en bloc transurethral resection and a multitude of novel systemic or intravesical treatment strategies, including immunomodulatory, viral, molecularly targeted and/or cytotoxic therapies as well as novel drug delivery mechanisms and chemoablation, are expanding treatment options, particularly for patients with Bacillus Calmette-Guérin-unresponsive disease. For patients with MIBC, refinements in surgical techniques and new neoadjuvant and/or adjuvant systemic therapies, particularly perioperative immunotherapy and potentially antibody-drug conjugates, continue to improve oncological outcomes. Bladder-preserving approaches such as trimodal therapy or even active surveillance following neoadjuvant therapy are also gaining clinical traction, offering selected patients with MIBC an alternative to radical cystectomy. Advances in the identification and application of circulating tumour DNA-based and tumour tissue-based biomarkers will help to further support personalized treatment and follow-up strategies. In this Review, we discuss progress and changes in the management of localized bladder cancer over the past decade and highlight ongoing innovations and future research directions that will shape clinical practice in the coming decade.