Cystectomy Remains Standard of Care Following Neoadjuvant Therapy in Patients with Muscle-Invasive Bladder Cancer

Radical cystectomy remains the standard of care after neoadjuvant therapy for muscle-invasive bladder cancer. While newer regimens (NIAGRA, KEYNOTE-B15/905) achieve impressive pathological complete response rates, the survival benefits from these trials were built on consolidative surgery, with a 88% cystectomy rate bladder preservation. Clinical complete response agrees with true pathological complete response only about half the time, meaning current restaging tools cannot reliably identify who is truly disease-free. Bladder preservation trials using systemic therapy alone (RETAIN-1/2, HCRN GU 16-257) have shown concerning rates of recurrence and metastasis even with biomarker selection. Trimodal approaches incorporating radiation (IMMUNOPRESERVE, INDIBLADE) are promising but remain early-phase. Until validated biomarkers and prospective trials prove otherwise, cystectomy should remain part of the curative-intent treatment paradigm.