Alternatives to radical cystectomy: a bladder-sparing approach in appropriately selected patients

Radical cystectomy (RC) has historically been the standard treatment for muscle-invasive bladder cancer (MIBC); nonetheless, it is associated with a high morbidity and mortality, with complication rates often exceeding 60%, a relatively high 90-day mortality rate, as well as a significant impact on quality of life (QoL). This substantial burden has generated increasing interest in effective bladder-sparing alternatives. Among these approaches to bladder preservation, trimodal therapy (TMT), comprising maximal transurethral resection of bladder tumour (TURBT) followed by concurrent chemotherapy and radiotherapy (chemoRT) using radiosensitising agents, has become a guideline accepted alternative to RC in appropriately selected patients with MIBC. Additional bladder-sparing strategies, such as TURBT monotherapy or TURBT followed by systemic therapy and surveillance in those patients achieving a complete clinical response, may be alternatives in select settings, although data are limited. Appropriate surveillance after a bladder-sparing approach is paramount to offer timely salvage RC when needed, occurring in approximately 11-16% of contemporary TMT cohorts. QoL outcomes consistently favour TMT over RC, particularly in preserving urinary and sexual function. Severe treatment-related toxicity with TMT is uncommon, with Grade ≥3 adverse events occurring in <10% of cases. In conclusion, bladder-sparing approaches offer a suitable alternative to RC in appropriately selected patients with MIBC, incorporating multidisciplinary care and a commitment to lifelong surveillance.