How do the outcomes of bladder-sparing protocols compare to radical cystectomy?

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

Bladder-sparing protocols have been advocated as a treatment option because they may salvage the native bladder and may offer better quality of life than radical cystectomy does. These protocols entail a complex treatment schedule, including transurethral local bladder resection, systemic chemotherapy, and radiotherapy with a radiation sensitizer. Local recurrences and disease-free survival are comparable with those of traditional radical cystectomy, and the patient avoids (or delays [40% of cases]) a significant surgery and potentially maintains native bladder function. Which patients benefit from a bladder-sparing approach remains unclear.

The concern that intravesical therapy may preclude the possibility of definitive therapy appears to be minor. In a group of 313 patients with high-grade Ta, T1, or CIS initially treated with BCG and ultimately with cystectomy, disease-specific survival rates were similar in those who underwent cystectomy within one year of initial BCG treatment to those who had received more than one year of BCG treatment prior to cystectomy. [35]

The most optimistic trials of bladder-sparing protocols to date report an approximate 40% 5-year survival rate with an intact bladder. Of patients whose conditions respond completely, 50%-60% experience tumor recurrence in the bladder; half of these recurrences are invasive and carry an increased risk of metastatic spread. [36]

Although no economic comparisons, randomized trials, or unflawed quality-of-life trials are available to debate the merits of a bladder-sparing versus radical surgical approach, a bladder-sparing approach is a reasonable option for select patients. Patients who may not tolerate surgery or have a strong sentiment towards maintaining their native bladder are excellent candidates for a bladder-sparing multimodal approach.


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