Clinically necessary Expert consensus on the preservation of comprehensive bladder treatment for muscularly invasive bladder cancer

Radical cystectomy (RC) is the main surgical modality for the treatment of muscularly invasive bladder cancer (MIBC) and is effective in improving patient survival
.
However, RC surgery is traumatic and has many postoperative complications, affecting the quality of life of patients; There will also be a certain perioperative case fatality rate
.
In addition, some patients may be unwilling or unable to tolerate RC
.
Reserved bladder combination therapy can be used as an alternative treatment option
for patients with MIBC who are unwilling or unsuitable for radical surgery.
The Urology Branch of the Chinese Medical Association and the Chinese Bladder Cancer Alliance have launched the "Expert Consensus on the Comprehensive Treatment of Preserved Bladder for Muscle-Invasive Bladder Cancer", and the medical pulse is organized as follows
.

For patients with MIC whose physical conditions can tolerate RC and have good adherence, 96.
10% of experts believe that patients with cT2N0M0 stage can choose to retain the bladder according to their own wishes and reach a consensus; 40.
30% of experts believe that cT3aN0M0 patients also have the opportunity to retain the bladder, and only a very small number of experts believe that patients with cT3bN0M0 stage ≥ can actively choose to carry out bladder preservation therapy
.
81.
8% of experts agreed on the comprehensive application of novel biomarkers to guide the screening of ideal patients
for bladder retention therapy.

Most experts consider patients with tumor-associated hydronephrosis, carcinoma in situ of the bladder, prostate urethral tumor, squamous cell carcinoma, neuroendocrine tumor, bladder adenocarcinoma, urothelial carcinoma with squamous differentiation, and urothelial carcinoma with glandular differentiation not suitable for bladder retention
.

There are two main surgical modalities for MIBC bladder retention: maximum transurethral bladder treatment resection (cTURBT) and partial bladder resection (PC
).

cTURBT refers to the complete excision of the bladder treatment visible to the naked eye and is a vital part
of the comprehensive treatment of the MIBC to preserve the bladder.
92.
2% of experts believe that cTURBT must be completely removed from the visible lesion, and the margin, substrate, and biopsy of the available lesion must be negative
.
For tumors that cannot be completely removed by cTURBT, PC
may be considered in specific patients.
Compared with TURBT, PC combined with pelvic lymph node dissection provides more accurate staging and adequate evaluation
of surgical margins.

In clinical practice, there is still no unified standard for the specific implementation plan of bladder retention, and it is necessary to make a comprehensive choice
according to the individual patient's situation and the technical conditions of implementation.
Comprehensive bladder-sparing therapy emphasizes the combination of radiotherapy and chemotherapy on the basis of surgical complete removal of tumors, of which cTURBT combined with systemic chemotherapy and local radiotherapy TMT is currently the most evidence-based medical protocol
.
On the basis of local surgical resection, 84.
22% of experts recommended combined with concurrent chemoradiotherapy (TMT) and 75.
30% of experts recommended combined with concurrent chemoradiotherapy and immunotherapy
.

Whether intravesical perfusion therapy is required to achieve complete remission (CR) after concurrent chemoradiotherapy to prevent intraluminal recurrence is an important clinical issue
in the comprehensive treatment of bladder retention.
63.
64% of experts believe that intravesical perfusion therapy is required after the end of simultaneous chemoradiotherapy
.

Conservative treatment regimens for MIBC during neoadjuvant chemotherapy, and several large prospective studies have confirmed that cisplatin-based neoadjuvant chemotherapy can benefit patients with MIBC in
survival.
However, whether chemotherapy before TMT can improve the efficacy of direct TMT is still inconclusive
.
This time, 63.
64% of experts agreed to retain the option of comprehensive bladder treatment and could choose straight TMT; 54.
55% of experts believe that patients who have reached CR or close to CR after 3-4 cycles of neoadjuvant therapy (Ta/Tis stage) can choose TMT; 61.
04% of experts recommend that patients with CR receive maintenance immunotherapy after TMT treatment, but there is no consensus
.
If there is a suspicious lesion (cystoscopy or urine cytology/FISH test positive) after the end of the MIBC-reserved bladder comprehensive treatment, 81.
82% of experts believe that TURBT is needed again and reach a consensus
.

Experts recommend that all patients with MIBC undergo comprehensive bladder retention therapy should be closely followed up and monitored
.
Follow-up and monitoring can improve the self-management level of bladder cancer patients, timely detection of recurrences and effective treatment, to a certain extent, to ensure the efficacy and quality
of life of patients.
Most experts believe that follow-up tests include: cystoscopy, urine cytology, CT/MRI
.

After receiving bladder retention therapy in MIBC patients, 26% to 31% of patients develop non-myoinvasive bladder cancer (NMIBC) recurrence
.
For patients with NMIBC recurrence, if the recurrence lesions are Tis, ≥ T1 stage, and high-grade tumors, about 70% of experts recommend salvage RC; In the case of Ta-stage or low-grade tumor recurrence, 82.
00% of experts do not agree that immediate salvage RC is used, and the use of TURBT+ bladder perfusion is the salvage treatment option
for patients with NMIBC recurrence.

Table 1 The consensus of MIBC retains the content of comprehensive bladder treatment

Edit: LR

Reviewer: LR

Execution: Wang Mumu