Organ-conserving approaches to muscle-invasive bladder cancer: future alternatives to radical cystectomy

Abstract

In the USA radical surgery remains the golden standard for invasive bladder cancer. Yet in most other areas of surgical oncology the trend of the 1990s has been towards organ conservation with chemoradiation with or without limited local surgery. Patients with breast, oesophageal, anal, lung and larynx cancer are routinely offered conservative therapies as valid options in the management of their diseases but bladder stands apart from the crowd. Evidence is presented here to show that this need not be the case. Four older randomized trials failed to show a survival advantage when immediate cystectomy was compared with radiation followed by salvage cystectomy, if required. Five and 8-year survival rates for clinically staged patients treated by transurethral resection and chemoradiation (trimodality therapy) in several modern, large and mature series show survival rates comparable to those reported in contemporary radical cystectomy series. Eighty per cent of those alive 5 years after chemoradiation still retain their native bladder. Although superficial relapse occurs in 20% of cases, it remains responsive to BCG (Bacilles bilie de Calmette-Guerin) in the manner of de novo superficial disease. Quality-of-life studies show that the retained bladder functions well. At the Massachusetts General Hospital and in the multicentre prospective trials, less than 1% of patients needed cystectomy for bladder morbidity. It is of note that continent diversions may be performed as salvage after contemporary radiation therapy. Trimodality therapy is a novel and contemporary approach that owes little to the radiation treatment offered in the 1970s. While it will never entirely take the place of radical cystectomy, it should be offered as a reasonable alternative to patients with a new diagnosis of bladder cancer. This multidisciplinary approach will allow uro-oncology to keep in step with the oncological vanguard.

Incidental Prostate Cancer at the Time of Cystectomy: The Incidence and Clinicopathological Features in Chinese Patients

“…RCP has traditionally been considered as a golden standard for the treatment of muscle-invasive bladder cancer [3]. However, the risk of erectile dysfunction and urinary incontinence following this procedure is considerable and might delay the patients' acceptance of RCP, which can adversely affect the prognosis of these patients.…”

“…It leads to significant morbidity and mortality. Up till now, RCP remains the golden standard for muscle invasive bladder cancer or recurrent superficial urothelial carcinoma at high risk [3]. Although the neobladder reconstruction and nerve-sparing technique offer a better quality of life for the patients, the recovery of erectile function and urinary continence after surgery are still far from satisfactory [4].…”

Bladder Cancer

“…External‐beam radiation therapy alone as definitive treatment, although not used frequently in the United States, is considered to be the standard of care in some countries, and, until recently, it was the main alternative to radical cystectomy 2 . Trimodality therapy (TUR, radiation, and systemic chemotherapy) has emerged as the most effective of the bladder‐preserving treatment protocols 52 . All patients begin with TUR and an induction course of radiation and chemotherapy.…”

Robot‐assisted radical cystectomy: Review of surgical technique, and perioperative, oncological and functional outcomes

“…A comprehensive preoperative evaluation of the patient’s medical conditions, including detailed medical and surgical history, and comprehensive assessment, are mandatory. Addressing the modifiable risk factors is crucial by encouraging breathing exercises, smoking cessation, diet counseling and nutritional supplementation for malnourished individuals . Comprehensive preoperative counseling has been shown to motivate patients, improve recovery and reduce complications .…”