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Bladder preservation treatment options for muscle-invasive urothelial bladder cancer

Jason A Efstathiou, MD, DPhil
Philip Saylor, MD
Matthew Wszolek, MD
Nicholas J Giacalone, MD
Section Editors
Seth P Lerner, MD
Derek Raghavan, MD, PhD, FACP, FASCO
W Robert Lee, MD, MS, MEd
Deputy Editor
Michael E Ross, MD


Bladder cancer is the most common malignancy of the urinary system, with an estimated 79,000 new cases and 17,000 deaths in the United States annually [1]. Worldwide, bladder cancer accounts for approximately 540,000 new cases and 188,000 deaths [2]. In developed areas of the world, such as North America and Western Europe, these bladder cancers are predominantly urothelial.

Nearly 70 percent of new bladder cancer diagnoses are early-stage (ie, Ta, Tis, and T1 disease (table 1)) and have not yet invaded the muscular layer of the bladder wall. These patients are often managed with transurethral resection of bladder tumor (TURBT) with or without adjuvant intravesical therapy. The remaining 30 percent of patients have muscle-invasive bladder cancer, including cancer involving the muscularis propria (T2), perivesical tissue (T3), or adjacent pelvic organs/structures (T4).

Radical cystectomy remains the cornerstone of curative treatment for muscle-invasive urothelial bladder cancer. Radical cystectomy involves removal of the bladder (in combination with removal of the uterus/ovaries/fallopian tubes and possibly a portion of the vagina in women, and the prostate and seminal vesicles in men), pelvic lymph node dissection, and reconstruction of the urinary tract. The morbidity and long-term outcomes of cystectomy are well documented [3].

Because of the high risk of distant failure in muscle-invasive bladder cancer, systemic chemotherapy either before or after radical cystectomy is often recommended to improve outcomes. Modern series of patients managed with radical cystectomy have a five-year pelvic control rate of nearly 80 percent and five-year overall survival rates ranging from 40 to 60 percent [4,5].

Modern oncologic therapies are increasingly driven towards organ preservation and maximizing functional outcomes while maintaining treatment efficacy. Combined-modality therapy (CMT) incorporating maximal TURBT followed by radiation therapy with concurrent radiosensitizing chemotherapy can be a comparably effective regimen to preserve a functioning bladder in well-selected patients who are either poor candidates for radical cystectomy or patients who are motivated to maintain their native bladder. This combined modality approach utilizing TURBT followed by radiation therapy with concurrent chemotherapy is often referred to as trimodality therapy (TMT).

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Literature review current through: Nov 2017. | This topic last updated: Oct 05, 2017.
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