Bladder preservation possible in select MIBC patients

Neoadjuvant chemotherapy (NAC) with transurethral resection (TUR) for bladder preservation is feasible for some patients with muscle-invasive bladder cancer (MIBC) who meet established selection criteria, suggests a study. However, recurrence may occur beyond 10 years, warranting lifetime surveillance.

“Bladder preservation was associated with an excess mortality risk of 11 percent at 15 years, which the patient and physician must consider when electing bladder preservation,” the researchers said.

An institutional retrospective review was performed in 101 prospectively monitored patients who met the “ideal” criteria for bladder preservation and achieved a clinical complete response to cisplatin-based chemotherapy and TUR from 1994 to 2015, with >10 years of follow-up. Bladder-intact survival, local recurrence-free survival, and cancer-specific survival were the primary endpoints.

The risk of bladder cancer at 15 years was 11 percent (95 percent confidence interval [CI], 5.8–18), with the competing risk of death from other causes of 44 percent (95 percent CI, 33–54) and cystectomy risk of 11 percent (95 percent CI, 5.9–18). [J Urol 2025;214:591-600]

Based on the findings, patients could be informed that over the course of the next 15 years, for a set of 100 patients with MIBC, 40 will have died from another cause, 40 will be alive with their bladder intact, 10 will have had to undergo cystectomy, and 10 will have died of bladder cancer.

“Bladder preservation outcomes were near 40:40:10:10 for death from another cause, alive with an intact bladder, cystectomy, and death from bladder cancer,” the researchers said. 

Of the patients, 41 were alive with their bladder intact over a median follow-up time of 14 years. A third of them relapsed locally, with the probability of recurrence persisting beyond 10 years, which required lifetime surveillance.

 “Our findings may not be generalizable to other settings or to patients not meeting ‘ideal’ criteria,” the researchers said.

Mortality

For patients with local recurrences, cystectomy may help extend their survival. Overall, the cumulative probability of death was 5.9 percent (95 percent CI, 2.4–12) at 5 years and 11 percent (95 percent CI, 5.8–18) at 15 years. For those who relapsed in the bladder (n=38), the mortality rates were 13 percent (95 percent CI, 4.7–26) and 26 percent (95 percent CI, 14–41), respectively.

“Furthermore, if we assume that all the patients who died of disease with or without a relapse in the bladder would have been cured by a planned post-NAC cystectomy, then the estimated excess mortality risk at 15 years would be 11 percent, in line with other methods of bladder preservation,” the researchers said. [J Clin Oncol 1998;16:1298-1301; Eur Urol 2014;66:120-137; Urology 2019;130:20-21]

“Taken altogether, this information is useful in counselling patients meeting ideal selection criteria and wishing to consider bladder preservation,” they added.

The current study was limited by its single-centre design, and the findings could be generalized to other practice settings and patient populations not meeting the established ideal selection criteria.