Organ preservation approaches with radiation therapy in muscle-invasive bladder carcinoma

Combined modality treatments with organ preservation intent have become standard oncological treatment in many tumour sites. Although radical cystectomy had been considered to be the standard treatment, combined modality treatment has been used in muscle-invasive bladder carcinoma with excellent results, especially in patients with T2-3a disease without obstructed ureters. The components of the combined treatment are usually transurethral resection of bladder tumour (TURBT) followed by concurrent chemotherapy and radiation. Interim cystoscopic assessment after the initial portion of radiation is often utilised to identify patients at high risk of local failure, ie. those who do not achieve a complete response, and these patients are then recommended to undergo immediate salvage cystectomy. Delaying cystectomy does not appear to decrease the survival or increase the incidence of distant metastasis. The local control rates for TURBT alone, chemotherapy alone and radiation therapy alone are only 20%, 20% and 30% to 45% respectively. When the above three are combined together, a complete response rate of 75% can be achieved and 85% of these remain free from invasive recurrence. Combined modality treatment offers an overall survival rates which is comparable with modern radical cystectomy series: about 50% at 5 years, and in addition, it offers a 5-year survival rate with an intact bladder of 41% to 43%. With the close collaboration among urologists, medical oncologists and radiation oncologists, organ preservation approaches can achieve excellent results in muscle-invasive bladder carcinoma and this option should be presented to patients as an alternative to radical cystectomy.