The gold standard of treatment for invasive bladder cancer (MIBC) is radical total cystectomy. However, there are still several major problems with radical total cystectomy.
1, The bladder is an organ responsible for storing and emptying urine, and no other body tissue or organ can replace its function.
2, Radical cystectomy is a major surgery with more complex techniques and more postoperative complications (perioperative mortality rate 1.5%-4.2% and complication rate 58%-67%), which not all patients can tolerate.
3. Regardless of the technical means used, the vast majority of patients are affected by sexual function after radical cystectomy.
4. Regardless of the diversion method, it is accompanied by a reduced quality of life (stoma care, regular urination, blood tests, etc.) and the dignity of the person is affected, so that the ability to urinate normally is missed only when the ability to urinate is lost.
How to solve these problems?
Reduced surgical trauma and holistic treatment is a viable solution! As the idea of “tumor is a systemic disease” has been confirmed by more and more studies and understood by more and more people, the application of integrated treatment (surgery combined with radiotherapy, targeted therapy, immunotherapy, etc.) in MIBC is also increasing. Based on the above, for patients with muscle invasive bladder cancer who are physically unable to tolerate radical cystectomy or unwilling to undergo radical cystectomy, bladder-preserving combination therapy is also gradually starting to be used in MIBC. so we should not give up lightly on such an important organ as the bladder.
Given the high proportion of lymph node metastases in muscle-invasive bladder cancer, patients considered for bladder-preserving treatment need to be carefully selected, with comprehensive assessment of tumor nature and depth of infiltration, proper selection of bladder-preserving surgery, supplemented by postoperative chemotherapy and radiation therapy, and close postoperative follow-up and, if necessary, salvage cystectomy. Preservation of the bladder is best indicated in patients with: a single, primary, small tumor that is located in the bladder apex and/or anterior wall and away from the bladder neck, negative basal and marginal biopsy of the resected surface, clinical stage T2-3, except for a history of Tis and superficial tumors, and no associated upper urinary tract complications. less than 5% of MIBCs meet these criteria. There are two surgical options for bladder preservation in muscle-invasive bladder cancer: transurethral resection of bladder tumor (TURBt) and partial cystectomy. For most patients with bladder-preserving muscle-invasive bladder cancer, the tumor can be removed by the transurethral route. However, partial cystectomy should be considered for some patients: patients with tumors located within the bladder diverticulum, around the ureteral opening or tumors located in the blind area of transurethral surgical operation, patients with severe urethral strictures and metaphasic tolerance of amputation, patients with preoperative imaging suggestive of upper urinary tract fluid and enlarged pelvic lymph nodes. Surgery should be performed to maximize resection of the tumor. Recently, it has been suggested that for patients with stage T2, repeat TURBT within 4-6 weeks after initial TURBT combined with chemotherapy and radiotherapy can help preserve the bladder.
Common features of bladder preservation are.
1, first TURBT to maximize resection of the tumor to clarify the stage.
2. using concurrent radiotherapy, with the chemotherapy regimen mostly chosen as a combination based on cisplatin (DDP), or with 5-FU, or with adriamycin.
3, radiotherapy followed by cystoscopy to assess the efficacy, and then switch to radical cystectomy if the treatment is unsuccessful. In the bladder-preserving comprehensive treatment modality, the accurate and thorough performance of TURBT is the key to the success of this modality, and all tumors visible under cystoscopy should be removed as much as possible to obtain a more accurate pathological staging. At the follow-up of patients who have achieved complete remission at the end of all treatments, TURBT can still be performed if isolated superficial lesions are found, thus preserving the bladder as much as possible.
The current treatment options for bladder preservation are as follows.
1. TURBT alone: It can be used only for a small number of patients whose tumors are confined to the superficial muscular layer and who have a negative basal biopsy of the tumor. In contrast, for stage T3 tumors, complete resection cannot be achieved by TUR surgery alone. Therefore, in the absence of special circumstances, pure radical TURBt surgery should not be used for the treatment of MIBC.
2.TURBT combined with external radiation therapy: mainly for patients who are not suitable for radical bladder cancer surgery or cannot tolerate chemotherapy. This group of patients has a 5-year survival rate of 30%-60% and a tumor-specific survival rate of 20%-50%.
After 3 cycles of chemotherapy, re-evaluation by cystoscopy and biopsy, if there is no residual lesion, we should also be alert to the possibility of residual lesion; if the lesion is still present, salvage total cystectomy is performed.
4.TURBT combined with radiotherapy and chemotherapy: radiotherapy combined with cisplatin-based synchronous chemotherapy (as a radiosensitizer) is currently the most common and most studied treatment option for bladder preservation in muscle-infiltrating bladder cancer. After complete TURBT, 40 Gy of external irradiation (often 4 radiotherapy fields) is administered; and two cycles of cisplatin-based regimens of synchronized chemotherapy are given at weeks 1 and 4. After these induction treatments, endoscopic evaluation is repeated, and if no tumor is seen on cystoscopy and cytology and biopsy are negative, 25 Gy of consolidation external irradiation radiotherapy combined with one cycle of cisplatin-based chemotherapy is added. The following radiotherapy sensitization regimens are all currently considered for simultaneous radiotherapy with bladder preservation after maximal TURBT: cisplatin (class 2A recommendation), cisplatin + 5-FU (class 2A recommendation), 5-FU + mitomycin (class 2A recommendation), cisplatin + paclitaxel (class 2B recommendation), and low-dose gemcitabine (class 2B recommendation). After maximal transurethral electrodesiccation, cisplatin-based chemotherapy combined with radiotherapy results in complete remission rates of 60%-80% , preserving an intact bladder for 4-5 years in 40%-45% of patients, and long-term survival of 50%-60% (comparable to radical cystectomy). If the combined treatment is not sensitive, early radical cystectomy is recommended.
5. Partial cystectomy combined with chemotherapy: The indications for partial cystectomy are: solid, primary, no in situ cancer that provides a 2 cm surgical margin without the need for ureteral transplantation. Less than 5% of muscle-infiltrating bladder cancers can be cured by partial cystectomy. Total cystectomy can be avoided in approximately 27% of patients.
Because it is difficult to achieve ideal bladder preservation with a single treatment, bladder preservation is currently treated with a triple combination of surgery, chemotherapy, and radiation therapy. The indications for the selection of this treatment regimen must be strictly controlled and the patient must have good compliance in order to obtain a better treatment outcome. Studies have shown that patients treated with TURBT followed by cisplatin-based chemotherapy and radiation therapy can achieve a treatment efficiency of 60-80%, but patients must be closely monitored and the treatment regimen must be adjusted in a timely manner.
With radical cystectomy, patients have an overall 5-year survival rate of 54.5% to 68% and a 10-year survival rate of 66%. However, the cost was the loss of the bladder. The overall 5-year survival rate for patients with muscle-invasive bladder cancer treated with bladder-preserving combination therapy is 45%-73% (comparable to radical cystectomy), and the overall 10-year survival rate is 29%-49%, with the benefit of preserving the bladder, improving quality of life, and the opportunity for salvage surgery even if the tumor recurs.
Therefore, it can be concluded that radical total cystectomy remains the gold standard of treatment for MIBC at this time, but comprehensive bladder preservation therapy deserves a place in the management of MIBC. A successful bladder preservation strategy requires an experienced multidisciplinary treatment team including radiotherapists, oncologists, and urologists, and patients must be prepared to undergo lifelong cystoscopic follow-up as well as cystectomy in case of invasive recurrence. The risk of developing disease progression and disease metastasis is inevitable, and the corresponding financial burden is increased, so patients should be well informed, combine the pros and cons, and make their own choices.