Localised muscle-invasive bladder cancer (MIBC) has historically been treated with radical cystectomy (RC), but bladder preservation therapy (BPT) has emerged as a credible and increasingly refined alternative. Early work by Herr in the 1980s demonstrated that radical transurethral resection of bladder tumour (TURBT) alone could achieve durable control in a small, carefully selected subset of patients. Since then, trimodal therapy (TMT), comprising maximal TURBT, radiosensitising systemic therapy, and radiotherapy, has become the most established bladder-preserving approach. More recently, systemic therapy-only strategies have been explored, as illustrated by the RETAIN and HCRN GU16-257 trials. Despite these advances, TMT remains the most widely adopted BPT, with ongoing challenges related to patient selection, protocol standardisation, response assessment, and biomarker integration. In this issue of European Urology, the International Bladder Cancer Group (IBCG) presents multidisciplinary consensus recommendations on BPT for MIBC. These guidelines address important inconsistencies across existing recommendations and provide practical direction while highlighting key evidence gaps. A major limitation to wider adoption of TMT remains uncertainty in patient selection. Randomised trials comparing TMT with RC are lacking, as exemplified by the early closure of the SPARE trial, leaving comparative data largely dependent on propensity-matched analyses. Importantly, the completeness of pre-treatment TURBT, an unmeasured but critical determinant of outcomes, introduces substantial selection bias. Beyond oncologic efficacy, functional outcomes and quality of life (QoL) warrant greater emphasis. Extensive or repeated TURBT, radiotherapy, and prolonged salvage intravesical therapies can cumulatively impair bladder function, particularly in previously irradiated patients. While oncologic salvage is often feasible, serial treatments may result in progressive QoL deterioration, underscoring the need for patient-reported outcomes to inform decision-making. Heterogeneity in TMT delivery further limits generalisability, including variability in surveillance strategies, nodal irradiation and the use of neoadjuvant chemotherapy. The IBCG appropriately recommends induction chemotherapy before chemoradiation for patients at highest risk of extravesical disease. Finally, defining a clinical complete response remains challenging, with emerging interest in endpoints such as event-free survival and novel biomarkers including circulating and urinary tumour DNA. Continued refinement of these tools will be essential as bladder preservation strategies evolve.
The future of bladder preservation for muscle-invasive bladder cancer
Reviewed by Asif H Ansari
The future of bladder preservation for muscle-invasive bladder cancer.
