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

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 1990 s has been towards organ conservation with chemoradiation with or without l imited local surgery. Patients with breast, oesophageal, anal, lung and lar ynx 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 old er randomized trials failed to show a survival advantage when immediate cys tectomy was compared with radiation followed by salvage cystectomy, if requ ired. Five and 8-year survival rates for clinically staged patients treated by transurethral resection and chemoradiation (trimodality therapy) in sev eral modern, large and mature series show survival rates comparable to thos e reported in contemporary radical cystectomy series. Eighty per cent of th ose alive 5 years after chemoradiation still retain their native bladder. A lthough superficial relapse occurs in 20% of cases, it remains responsive t o BCG (Bacilles bilie de Calmetre-Guerin) in the manner of de novo superfic ial disease. Quality-of-life studies show that the retained bladder functio ns well. At the Massachusetts General Hospital and in the multicentre prosp ective trials, less than 1% of patients needed cystectomy for bladder morbi dity. It is of note that continent diversions may be performed as salvage a fter contemporary radiation therapy. Trimodality therapy is a novel and con temporary approach that owes little to the radiation treatment offered in t he 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 d iagnosis of bladder cancer. This multidisciplinary approach will allow uro- oncology to keep in step with the oncological vanguard.