Radical cystectomy is the standard treatment for muscle-invasive bladder cancer. However, bladder preservation strategies can be considered for select patients to maintain quality of life. Bladder preservation involves either single modality treatment like chemotherapy or radiotherapy, or trimodal therapy using transurethral resection, chemotherapy and radiotherapy. Trimodal therapy provides oncological outcomes equivalent to cystectomy for early stage tumors if strict criteria are met. Close surveillance is needed after bladder preservation due to risk of recurrence. Salvage cystectomy may be required for muscle-invasive recurrences.

1. BLADDER PRESERVATION IN
CARCINOMA BLADDER
DR BRIGHT SINGH
MBBS,MS,MCh(Sur.Onco),D.Lap,FIAGES,FMAS,FAIS

4. • Non muscle invasive
• Muscle invasive
• Metastatic disease.

5. 70 percent early stage (Ta, Tis, and T1 disease)
30 percent of muscle-invasive bladder cancer
- muscularis propria (T2)
- perivesical tissue (T3)
- adjacent pelvic organs/structures (T4).
One-fifth of early stages will progress to muscle
invasive
Muscle-invasive bladder cancer (MIBC) is highly
fatal, and if untreated, >85% of patients die
within 2 years of diagnosis.

9. • Radical cystectomy remains the cornerstone of curative
treatment for muscle-invasive urothelial bladder
cancer.
• .
• Because of the high risk of distant failure in muscle-
invasive bladder cancer, systemic chemotherapy either
before or after radical cystectomy is recommended to
improve outcomes.

10. COMPLICATIONS OF RADICAL
CYSTECTOMY
Perioperative morbidity
Patients with urothelial carcinoma, the entire
urothelium (from the renal calyces to the urethra)
is at risk of developing recurrent tumors
throughout a patient's lifetime
Bladder cancer survivors following radical
cystectomy can have a significant impact on their
quality of life with an ileal conduit leading to an
altered body image, and genitourinary or sexual
dysfunction

11. Radical cystectomy (RC) is the preferred
treatment of choice in patients with MIBC
Bladder preservation can be considered in
patients who are either
-Not fit for cystectomy
-Not willing to undergo cystectomy
- Older patients
- Significant comorbid illnesses

13. • No randomised controlled trial evidence directly
comparing surgery with bladder preservation.
• Selective bladder Preservation Against Radical
Excision (SPARE),
-Attempted to randomise, between surgery
and radiotherapy
- Trial was closed due to poor accrual.
The goal of bladder preservation is to achieve
cancer survival at least equivalent to RC and to
maintain good quality of life including sexual life.

14. BLADDER PRESERVATION STRATEGIES
Radical transurethral resection (TUR).
Partial cystectomy.
Radiation therapy (RT) techniques
- Definitive EBRT
- EBRT combined with brachytherapy
- Chemo radiotherapy
Chemotherapy
Tri Modal therapy

16. Bladder preservation could include single
modality treatment or trimodal therapy
Series involving single modality treatment,
including chemotherapy or radiation therapy,
have not been satisfactory, with 5-year
progression- free survival rates of less than
50%.
Multimodality treatment -alternative approach,
but the results have been equivalent to those
of cystectomy, and do not offer a better
outcome.

18. Patients should be informed
• The risk of new or recurrent carcinoma is highest at the
retained bladder, (50 percent or higher within three to
five years of treatment )
• Given these future risks, patients should be cautioned
about these potential risks with bladder preservation
approaches, particularly if they have a long anticipated
life expectancy on the basis of age and general health
• The patient should be informed of the lack of robust
evidence as to which of the two options is more
effective overall and of the potential impact on sexual
and bowel function as a result of the treatment

19. Radical Transurethral Resection
INDICATIONS
• Solitary tumors at the trigone, posterior, or lateral
walls with focal invasion into muscularis propria.
• cT2 tumors < 3cm,
• No concomitant CIS
• No residual tumor on re-TURBT
• No prostatic urethral involvement
• No hydronephrosis/no upper tract lesions

20. - Should only be performed in patients not
fit for more aggressive treatments
- Treatment is oncologically safe?
Few studies have demonstrated benefits of
TUR in small selected population.

21. RESULTSCancer specific survival was 81.9%, 79.5% and 76.7%, and
progression-free survival with bladder preservation was 75.5%, 64.9%
and 57.8% at 5, 10 and 15 years, respectively. Patient age had a
negative impact on overall survival on univariate (HR 0.842, p = 0.049)
and multivariate analyses (HR 1.062, p = 0.000), and according to
median and quartile age stratifications (p = 0.000 and p = 0.000,
respectively). However, age did not have a negative impact on cancer
specific survival even when following the same stratifications. Although
progression and recurrence were concentrated during the first 3 years
(70% and 65%, respectively), both steadily increased afterward. A
followup schedule was developed according to this sequence of
events.
CONCLUSIONSRadical transurethral bladder tumor resection is a reliable
therapeutic approach for patients with muscle invasive bladder cancer
after complete tumor resection and with negative biopsies of the tumor
bed. These results are consistent in all age ranges.

22. Partial Cystectomy
INDICATIONS
• Solitary muscle-invasive tumor < 5 cm that is located anteriorly, at
the bladder dome
• Within a bladder diverticulum-absence of muscle, difficult to
access(narrow neck),RT req is high,cystoscopic surveillance(un
reliable),poor bladder function
• Have good bladder capacity
• No concomitant CIS
• No hypercontractility of the bladder
CONTRA INDICATIONS
• The presence of multifocal tumors
• Tis- flat tumours
• Prostatic urethral involvement,
• Prior history of recurrent bladder or upper tract urothelial ca
• Acontractile bladders

23. ADVANTAGES
• Partial cystectomy allows complete
pathologic staging of the primary
tumor, and a standard or extended
pelvic lymph node dissection
• Preserving urinary and sexual
function
• Avoiding the need for urinary
diversion
Patients undergoing partial cystectomy may be
recommended to receive neoadjuvant
chemotherapy

24. DISADVANTAGES
• Blood loss
• Tumor recurrence in the midline scar or
abdominal cavity from tumor spillage-bladder
is opened during the procedure
• Risk of recurrent tumor in the residual bladder

25. RESULTSFor the 58 patients analyzed, overall 5-year survival
was 69% with a mean followup of 33 months (range 1 to
83). Of the patients 43 (74%) are alive with an intact
bladder, 39 (67%) are currently disease-free with an
intact bladder and 32 (55%) have been continuously
disease-free with an intact bladder. Seven patients
experienced a superficial recurrence and were treated
successfully while 15 patients experienced an advanced
recurrence. On univariate analysis CIS and multifocality
were related to superficial recurrence, and lymph node
involvement and positive surgical margin were related to
advanced recurrence. On multivariate analysis
concomitant CIS (odds ratio 7.05, p = 0.004) and lymph
node involvement (odds ratio 4.38, p = 0.031) were
predictors of advanced recurrence.
CONCLUSIONSIn highly selected patients with invasive bladder
cancer, partial cystectomy offers acceptable outcomes.
Concomitant CIS and presence of metastases to
regional lymph nodes predict advanced recurrence.

26. Radiotherapy
INDICATIONS
• Very weak or unfit for other treatment options
• Those who refuse operation

27. Definitive external beam RT
INDICATIONS
• Frail,older patients
• Medically unfit for other approaches in an effort to palliate local
symptoms.
Local recurrence after RT alone is reported in up to 70 percent of
patients, and five-year survival ranges from 20 to 40 percent.
COMPLICATIONS-haematuria,fecal incontinence
Definitive external beam RT is not considered an acceptable
alternative to radical cystectomy in otherwise healthy patients.
Brachytherapy
INDICATIONS
• Small (<5 cm) solitary muscle-invasive bladder tumor
Brachytherapy has been combined with external beam RT to provide
a radiation boost to the primary tumor.
In this highly selected population, outcomes appear to be similar to
those reported with radical cystectomy, although this has not been
demonstrated in randomized trials.

29. Primary chemoradiation
• Single-agent cisplatin
• combination of fluorouracil and mitomycin C .
Radiotherapy is generally administered 1.8–2 Gy per
day fractions and a total dose of 50 Gy is delivered
Higher doses improve long-term local control.
Higher radiotherapy doses increase toxicity,
including hematuria, urinary and fecal
urgency, abdominal complaints and fatigue

30. • level I evidence has clearly demonstrated the superiority of
combined chemoradiation over radiation alone
• Canadian trial was the only randomised controlled phase 3 trial
investigating a radiosensitising agent which had shown benefit of
adding cisplatin to radiotherapy in improving local control. The trial
did not have adequate power to demonstrate a survival benefit.
Several case series have been published showing benefit of
concomitant cisplatin with radiotherapy over radiotherapy alone .
Cisplatin is nephrotoxic drug and many bladder cancer patients do
not have adequate renal function to receive cisplatin safely.
• BC2001 trial showed that fluorouracil and mitomycin-C is a suitable
choice for radiosensitisation in MIBC in which hydronephrosis and
impaired renal function are commonly occurring issues. With
concomitant use of these drugs the 2 year locoregional disease free
survival improved significantly from 54% to 67%
• Gemcitabine which has an established role in MIBC in the
neoadjuvant and metastatic setting has shown benefits when given
concurrently with radiotherapy

32. Chemotherapy
• Chemotherapy in patients with MIBC can be
neoadjuvant or adjuvant primarily given before
RC.
• There are a number of studies and met analyses
that have demonstrated that neoadjuvant
chemotherapy before RC improves survival.
• The results showed that the median survival was
46 months in patients who were treated with RC
alone, as compared with 77 months in patients
who received neoadjuvant before RC.

33. Trimodal Therapy
The bladder-preserving approach to the
treatment of muscle-invasive bladder cancer is
usually a combination of three treatments –
• Radiation therapy
• Chemotherapy
• Complete TURBT
The combination of these three treatments is
called “trimodal therapy,” (TMT).

34. Trimodal Therapy
An ideal patient for trimodal therapy- INDICATIONS
• Small solitary tumors
• Complete TURBT
• Early clinical stage T2-T3a,
• Good bladder function and capacity,
• No carcinoma in situ
• No infiltration of prostatic stroma,
• No hydronephrosis,
With these strict criteria, only 6-19% of patients
with MIBC fit these criteria

35. CONTRA INDICATIONS
• Radiation is less effective if the bladder tumour is too bulky.
This means that TMT is not recommended if it measures
more than 5 cm (about 2 inches), can be felt by the
physician during a physical examination, or if the tumour
causes blockage of urine flow from one or both kidneys
(called “hydronephrosis”).
• Radiation is also less effective if there are cancer cells in
multiple areas of the bladder or if they’re associated with
areas of “carcinoma in situ” (a cancer stage called Cis or
Tis). These are flat tumours This is because of the increased
risk of recurrence of the cancer.
• It’s also important that you have good bladder function
before starting TMT. If you have a lot of problems with
frequent and urgent urination, TMT might not be suitable.

36. • Although there are no randomized controlled
trials comparing trimodal therapy versus RC,
several retrospective and prospective studies
have confirmed the effectiveness of trimodal
therapy in patients with MIBC and an
alternative to RC
• Due to the relatively better quality of life and
the preservation of the patient’s own bladder,
bladder preservation treatment strategy is
becoming an attractive alternative

38. Copyrights apply

39. TMT
• SPLIT COURSE
• US
• RT-entire pelvis
• Short time for cystectomy
• Less bowel ,bladder
toxicity
• Surgery and
reconstruction easy
• Massachusetts General
Hospital, the 5-year OS
rate is 52%; cT2 is 61%
and cT3-T4 is 41% .
• CONTINUOUS COURSE
• EUROPE
• RT-bladder/partial
bladder with additional
margin
• Uninterrupted course
• Rx- Short time period
• Erlangen, Germany, the 5-
year OS rate is 54%; cT2-
T3 is 45% and cT4 is 15%

43. A study of 226 long-term survivors with
muscle-invasive bladder cancer
compared patient-reported quality of
life in patients treated with CMT versus
radical cystectomy . In multivariable
analysis, patients who received CMT
had significantly better general health-
related quality of life than patients who
had a radical cystectomy. CMT also had
better bowel quality of life and
equivalent urinary quality of life
compared with radical cystectomy.
However, the patient's baseline urinary
function before treatment is an
important consideration, since patients
with very poor baseline urinary function
may not have a "bladder worth
sparing."

44. POST-TREATMENT SURVEILLANCE
AND TREATMENT
• Patients require close surveillance after bladder-preserving,
combined-modality therapy.
• Most recurrence occur in first 2 years
• Long-term bladder surveillance is critical since 20 percent
of de novo non-muscle-invasive bladder cancers occur after
10 years
• Office cystoscopies and urine cytology, which should be
performed every three months for the first two years, every
six months for years 2 to 5, and then yearly thereafter.
• Computed tomography scans of the chest/abdomen/pelvis
are performed every three to six months for the first one to
two years, every six months for years 2 to 5, and then
yearly.

45. MANAGEMENT OF BLADDER
RECURRENCES
General approach — Important factors in selecting appropriate therapy
• patient's overall health
• time of recurrence
• voiding symptoms
• tumor size
• pathologic stage
• pathologic grade at recurrence
Salvage cystectomy is recommended for patients who fail to have a complete
response as well as patients with a muscle-invasive bladder cancer
recurrence at any point.
Low-grade and noninvasive recurrences can be treated with transurethral
resection of bladder tumor (TURBT) along with adjuvant intravesical
therapy such as Bacillus Calmette-Guérin (BCG) or mitomycin.
Non-muscle-invasive bladder cancers with risk factors for progression such as
high-grade, carcinoma in situ (CIS), or T1 disease can be managed with
cystectomy or TURBT with BCG based on clinical judgment.

46. Conclusion
• The goal of bladder preservation is to achieve cancer
survival at least equivalent to RC and to maintain
quality of life including sexual life.
• Randomized controlled trials comparing BPT to RC are
acutely needed to better characterize patient selection
and compare survival outcomes
• Hence, it is important to carefully select the patient for
bladder preservation evaluating risk and benefits.
• Bladder preservation can be achieved using single
modality treatment; however, patients undergoing
trimodal therapy have better outcomes

47. THANK U