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Cicione et al. Mini-invasive Surg 2021;5:47 https://dx.doi.org/10.20517/2574-1225.2021.52 Page 5 of 11

Table 2. Current guidelines on bladder preserving approaches for MIBC

Association Patient selection criteria Radiotherapy Chemotherapy

AUA Highly selected patient Halt the radiation at a dose of 40-45 Gy (approximately 2/3 Many prospective studies have reported high rates of local control (> 70%) in patients
- Unfit for RC of the total dose), repeat a cystoscopy with re-biopsy, and, if selected for treatment on protocols that included cisplatin with or without 5-FU
- Tumor resecable by TURB (< 3cm) muscle invasive tumor still persists, recommend cystectomy
- Absence of multifocal CIS and hydronefrosis at that time
and T3/T4 tumors
- No histology variants
- Well informed patient (40% subsequent
RC)
- Adequate bladder function
- Follow-up
ESMO Option for patients seeking an alternative to In case of bladder preservation with radiotherapy, combination with a radiosensitiser is always recommended to improve clinical outcomes, such as
cystectomy and a palliative option for those cisplatin, 5FU/MMC, carbogen/nicotinamide or gemcitabine
who are medically unfit for surgery
Ideal patient: early tumour stage (including
high-risk T1 disease T2 < 5 cm), a visibly
complete
TURBT, absence of associated CIS and
ureteral obstruction and adequate bladder
capacity and function
Lifelong surveillance is required to achieve
optimal results
EAU Reasonable treatment option in well-selected A standard radiation schedule includes EBRT to the bladder Different chemotherapy regimens have been used, but most evidence exists for
patients as well as patients with a and limited pelvic LNs with an initial dose of 40 Gy, with a cisplatin and mitomycin C plus 5-FU. In addition to these agents, other schedules have
contraindication for surgery boost to the whole bladder of 54 Gy and a further tumour also been used, such as hypoxic cell sensitisation with nicotinamide, carbogen and
High level of patient compliance is need, boost, with a total dose of 64 Gy gemcitabine, without clear preference for a specific radiosensitizer
absence of carcinoma in situ, absence or
presence of hydronephrosis, optimal
debulking of initial cancer

AUA: American Urological Association; ESMO: European Society for Medical Oncology; EAU: European Association of Urology; MIBC: muscle invasive bladder cancer; RC: radical cystectomy.

Thus, 10%-30% of patients will require SRC after initial curative TMT with a mean 5-year DFS of 50% and 5-year OS rate of 33%-48%. However, those findings
may be biased, hypothesizing that all patients requiring SRC were fit for surgery and studies included only patients with ≥ T2 N0M0 bladder cancer. In patients

[23]
undergoing RC at primary MIBC diagnosis, Stein et al. showed an OS at 5 and 10 years of 78% and 56%, respectively, in the presence of organ confined
disease with no lymph node involvement. Those rates were dramatically reduced in the presence of extravesical disease extension (5-year OS = 55%; 10-year
OS = 27%) and lymph nodes involvement (5-year OS = 31%; 10-year OS = 23%).

However, the rate of disease-free survival after SRC is higher than in the absence of treatment. Martini et al. evaluated the natural history of MIBC in the
[24]
absence of treatment by analyzing 64 patients > 79 years old affected by T2-T4 N0 high-grade bladder cancer who did not receive any treatment. They found a