What are the alternatives to radical cystectomy for the treatment of bladder cancer?

Updated: Nov 27, 2016
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

See the list below:

  • Transurethral resection of bladder tumor (TURBT) alone: Risks include incomplete resection, a high rate of disease recurrence, and the potential for disease progression.

  • Systemic chemotherapy in combination with TURBT

    • This regimen has historically included methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC).

    • A doublet of gemcitabine and cisplatin has shown similar response rates to MVAC in the metastatic setting and is easier to tolerate; therefore, this regimen is often considered the first-line therapy. [10, 11]

  • Primary radiation therapy: This therapy is more commonly used in countries outside the United States for patients with T2 and T3 cancer. The 5-year survival rate is 20%-40% (less than radical cystectomy).

  • Gofrit et al compared the results of radical cystectomy with those of chemoradiation in 2 age-matched populations. Between 1998 and 2008, 33 patients were treated with chemoradiation for biopsy-proven T2-4aN0M0 urothelial bladder cancer. [12] For every patient treated with chemoradiation, the investigators found an age-matched patient who underwent radical cystectomy during the same year for comparison. The mean dose of radiation therapy was 62 Gy; the median follow-up period for both groups was approximately 36 months. The groups were similar with respect to age, proportion of men, and length of follow-up. The Charlson comorbidity index was significantly lower for patients who underwent surgery. The 2- and 5-year overall survival rates after surgery were 74.4% and 54.8%, respectively; after chemoradiation, 2- and 5-year overall survival rates were 70.2% and 56.6%, respectively. The 2- and 5-year disease-free survival rates after surgery were 67.8% and 63.2%, respectively; after chemoradiation,theywere63%and 54.3%, respectively. The investigators concluded that treatment with chemoradiation should be considered in patients with T2-4aN0M0 bladder cancer. [12]

  • Bladder-sparing multimodality therapy

    • Transurethral resection plus radiation therapy and concomitant cisplatin-based chemotherapy carries a 3- to 5-year estimated survival rate of 45%-64%. Delayed cystectomy is often required for palliation of symptoms or for recurrent disease. At 5 years following treatment, approximately 40% of patients are disease-free with their native bladder.

    • No significant improvement over up-front cystectomy has been shown, and the burden of therapy is often greater in patients who undergo multimodal therapy.

    • This therapy is considered only in patients who are highly motivated to preserve their bladder and reliably adhere to the rigorous surveillance protocol required.

  • Partial cystectomy: Partial cystectomy is for highly selected patients with a single tumor at a single point in time in a surgically amenable location who have no associated CIS and a bladder volume capable of tolerating a partial resection. Patients must be willing to accept the risk of local recurrence within the retained bladder and the risk of disease progression.


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