UroToday - Muscle infiltrating bladder cancer is a life-threatening disease. Despite diagnostic and surgical advancements in the last decade, after cystectomy 5-year disease recurrence rate is 30-40% even in referral centers. The introduction of orthotopic neobladder has greatly improved the quality of life and self-perception of patients undergoing cystectomy.

To date, radical cystoprostatectomy is the standard treatment of muscle-infiltrating bladder cancer. Although less aggressive cystectomy surgical techniques have been proposed, like seminal- and sexual-sparing cystectomy, they have been criticized for oncological risks.

However, with radiotherapy and chemotherapy protocols improvement, some authors have explored the possibility of preserving the bladder in muscle-infiltrating disease.

These studies should still be considered investigational, though some long-term data are now available.

Can we select patients who are likely to benefit from a conservative approach? Optimal candidates to bladder sparing protocols are patients with a single lesion, no extravesical extension, no hydronephrosis, with no or minimal residual tumor after Transurethral Resection of the Bladder (TUR) and/or after neo-adjuvant chemotherapy, and with no p53 overexpression. However, bladder sparing studies can also deal with patients in very poor conditions, unfit for surgery. Just a few series have reported results after repeated aggressive TUR alone for infiltrating bladder cancer.

Partial cystectomy with or without chemotherapy/radiotherapy can be a feasible option, but only a very small number of patients meet the criteria for this surgical approach.

Today the best option for bladder sparing in muscle infiltrating cancer is probably chemoradiotherapy. With the combined use of external beam radiotherapy and chemotherapy protocols, at 5 years disease specific survival approximates 50%. About forty-five per cent of surviving patients will retain the bladder.

Two major points must be strongly underlined:

1) The results of bladder sparing cannot be compared to cystectomy series, since patients entering bladder sparing protocols are usually either with very favorable prognostic factors or with very poor performance status.

2) No randomized trial has ever been performed to evaluate the results or cystectomy versus bladder sparing for infiltrating bladder cancer.

Patients undergoing a bladder sparing approach must be aware to enter a very strict surveillance protocol, that on long term may affect their quality of life. The psychological burden of repeated controls must be considered when offering bladder sparing to patients with infiltrating bladder cancer.

Chemoradiotherapy bladder sparing studies should be done in selected centers only, with a well tested experience in different team collaboration.

Again it must be emphasized that radical cystectomy, when feasible, should be the first option offered to a patient with infiltrating bladder cancer.

Paolo Emiliozzi, MD, as part of Beyond the Abstract on UroToday.

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