Bladder-Preserving Protocol for Locally Advanced Bladder Cancer

Patient Selection Criteria

The National Comprehensive Cancer Network recommends that ideal candidates for bladder preservation must have T2 disease less than 5 cm, solitary lesions, no carcinoma in situ, and no tumor-related hydronephrosis 1, 2, 3
The American Cancer Society suggests that surgical factors, such as visibly complete TURBT with pT0 status after repeat resection, are crucial for patient selection 2, 3
The European Association of Urology states that patient factors, including good performance status, adequate bladder capacity and function, and no obstructed ureters, are essential for bladder preservation 1, 4
The National Comprehensive Cancer Network guidelines indicate that patients with negative lymph nodes (N0) are suitable candidates for bladder-sparing procedures 1

The National Comprehensive Cancer Network recommends maximal transurethral resection of bladder tumor (TURBT) followed by concurrent chemoradiotherapy with cisplatin-based chemotherapy and radiation therapy to 64-65 Gy, with mandatory cystoscopic restaging to assess response and determine need for salvage cystectomy 1, 4
The European Association of Urology suggests that radiation therapy should be delivered to the pelvis using 3D conformal or IMRT techniques, with a dose of 45-50.4 Gy 2, 3
The American Cancer Society states that concurrent chemotherapy regimens, such as cisplatin alone or cisplatin + 5-fluorouracil, can be used during radiation therapy 2

The National Comprehensive Cancer Network reports that the 5-year overall survival rate for patients with locally advanced bladder cancer is 50-67% 2, 4
The European Association of Urology indicates that the bladder-intact survival rate at 5 years is 40-54% 1
The American Cancer Society states that the complete response rate after induction chemoradiotherapy is 70-87% 2
The National Comprehensive Cancer Network guidelines suggest that local control at 3 years is 73-96% with chemoradiation vs 69% with chemotherapy alone 1

The European Association of Urology recommends intensive monitoring, including cystoscopy with cytology every 3 months for the first 2 years, then every 6 months thereafter 2, 3, 5
The National Comprehensive Cancer Network suggests that imaging of the chest, abdomen, and pelvis should be performed every 3-12 months based on risk 6
The American Cancer Society states that upper tract imaging should be performed every 1-2 years for high-grade tumors 6

The National Comprehensive Cancer Network warns that up to 45% of bladders may be clinically understaged after TURBT, with residual disease found at cystectomy 1, 4
The European Association of Urology indicates that grade 3/4 hematologic toxicity occurs in 10-14% of patients during chemoradiation 1
The American Cancer Society states that patient selection errors, such as attempting bladder preservation in patients with hydronephrosis, can predict poor outcomes 1, 4

The National Comprehensive Cancer Network recommends that carboplatin should not be substituted for cisplatin in the bladder preservation setting, as it lacks equivalent efficacy 7

The National Comprehensive Cancer Network suggests that poor performance status makes patients unsuitable for the intensive trimodality approach requiring maximal TURBT, concurrent chemoradiation, and frequent monitoring 7, 8
Patients with extensive comorbid disease should be considered for alternative approaches such as TURBT alone, radiotherapy plus chemotherapy, or chemotherapy alone, as recommended by the National Comprehensive Cancer Network 8, 9

The National Comprehensive Cancer Network indicates that T3b and T4a disease with extensive extravesical extension has poor outcomes with bladder preservation, as the proportion rendered tumor-free is low 8
T4b disease or positive lymph nodes should be managed with systemic chemotherapy rather than bladder preservation attempts, according to the National Comprehensive Cancer Network 8, 9

Patients should undergo repeat TURBT if no muscle is present in the initial specimen or if resection is incomplete, as recommended by the National Comprehensive Cancer Network 7, 9

The National Comprehensive Cancer Network advises against attempting bladder preservation in patients with any degree of hydronephrosis, as this consistently predicts treatment failure 7
The National Comprehensive Cancer Network recommends never substituting carboplatin for cisplatin in the bladder preservation setting, even with borderline renal function 7
The National Comprehensive Cancer Network suggests avoiding bladder preservation in patients with diffuse CIS, as concurrent extensive CIS significantly reduces success rates 7