Bladder Preservation for MIBC - Past Present and Future

• 17 Sep 2020 08:42:32 AM
• |Onco Urology

Dear All,

Urothelial Bladder Cancer has emerged from its Orphaned state for long into probably the most researched GU Cancers of late. This has translated into better understanding of various treatment options that can be implemented for better survival for these patients. Molecular classifications with Genetic Subtyping have made rapid inroads in our understanding. From Cisplatin based Chemo either as adjuvant or Neoadjuvant has been replaced mostly with Immune Checkpoint Inhibitors and this has changed the management of MIBC, nay even NMIBC, to a considerable extent. Advances in RT and its dosages along with Radical Cystectomy (RC) with modifications have felicitated further in the treatment options we offer for such patients.

For long, Bladder Preservation Therapies (BPT) was being considered as a viable alternative to RC. RC need some form of Urinary Diversion which is not palatable to many patients with MIBC. Some of these patients decline RC due to this fact. In some selected cases Partial Cystectomies can be offered as Bladder Preservation. But in most instances Complete TURBT is an essential step in implementing BPT which may not be forthcoming in many, leading to disastrous results with BPT.

Cora Steinberg, a while ago mentioned that with properly Guided Chemo, a P0 state can even be achieved with Cisplatin based regime and now with Immune Check point inhibitors, this can be achieved more frequently. With Vi-RADS gaining Popularity in the staging of B Ca, a post Chemo assessment with Vi-RADS could be beneficial to assess the P0 state after the chemo regime (this is still in the pipeline).

In the article provided a table is available indicating the Appropriate indications and contraindications for BPT:

Preferred or ideal	Less than ideal	Contraindications
• T2 • No hydronephrosis • No CIS • Visibly complete TURBT • Unifocal tumour • Good bladder function and capacity	• T3a • Incomplete TURBT • Multifocal tumour • Poor bladder function or capacity • Diffuse CIS	• T3b–T4b • Lymph node-positive disease • Tumour-related hydronephrosis • Prior pelvic radiation therapy • Not a candidate for chemotherapy • Prostatic stromal invasion

I am sure all of us will benefit from reading and understanding this article being posted. The future appears to be in having some of treatment that could move away from RC with Urinary Diversion. If this could be realized, then many patients declining RC could be benefited.

With warm regards,

Venu

 

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