MIBC TMT Recent Advances and Unanswered Questions

Dear All,

The controversies surrounding Trimodality Therapy for Bladder preservation for MIBC is still real though at many centres practicing the regimes for TMT are reporting more favourable results than before. It is mentioned that many patients who are in the younger age group are opting for TMT with a hope that they would be able to void via naturalis.

Neoadjuvant Chemotherapy (NAC) is preferred than Adjuvant Chemotherapy after Radical Cystectomy (RC) by many of the experts and newer options of drugs are now available with which the response to NAC appear better. Hence many discuss regarding the possibility of TMT for patients who have favourable response to NAC as against their undergoing RC.

This excerpt provided addresses the protocol adopted by Princess Margaret Cancer Centre as regards TMT.

With warm regards,



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  • Ravindra Sabnis
    Ravindra Sabnis
    19 Mar 2020 07:01:29 PM


    About TMT - However attractive it may appear, whatever evidence it may have in literature, for MIBC, cystectomy still is the answer in our country,
    Even with NAC, if the response is excellent, tumor disappears, still none has suggested not to do cystectomy,. 
    I personally feel, bladder preservation is dream - which is far from reality in India. If he wants to void naturally, neobladder is answer. 

  • Venugopal P
    Venugopal P
    20 Mar 2020 11:47:55 AM

    Dear All,

    Urinary Diversion in which ever form is an ‘operation of Defeatism’ where we have accepted that the disease has forced us to do it for want of any other way. The concept that humans can live with a diverted urinary state came from many reptiles and other animals living with ‘Cloacal Arrangement’.

    Though we no longer favour Ureterosigmoidostomies in various forms, it should be realised that recently there has been an attempt at recognizing this. With Robotic Cystectomy coming to the fore, though Extra and intracorporeal constructions of Urinary diversions are preferred but due to the fact that its time consuming, some are considering the possibility whether Ureterosigmoidostomy could be reconsidered.

    Every form of diversion, be it using, Intestines or not is fraught with its own complications and this should be well understood and Orthotopic Bladder reconstruction is no exception for this.


    Another article worth reading and understanding is from IJU by Nikhil Vasdev

    http://www.indianjurol.com/article.asp?issn=0970-1591;year=2013;volume=29;issue=4;spage=310;epage=315;aulast=Vasdev (PDF available)


    It should also be realised that the definition for Urinary Diversion implies that Urine is taken away from its ‘via naturalis’ course. This means that any diversion procedure where the patient voids ‘per via naturalis’ should not be categorized as a procedure for urinary diversion. Taking this into consideration, Orthotopic Bladder reconstruction cannot be included as a Urinary Diversion.

    I am providing two articles, one by Nikhil Vasdev (2013) on ‘Continent Urinary Diversions’.

    http://www.indianjurol.com/article.asp?issn=0970-1591;year=2013;volume=29;issue=4;spage=303;epage=309;aulast=Moon (PDF available)


    The other article is by Liang G Qu and Nathan Lawrentschuk* (20190 on ‘Selection of patients for Orthotopic Neobladder’.


    Though, as Ravi has mentioned that there is no place for TMT in India, many patients, though the number for RC is increasing, opting out of RC for the fear of Diversion. If TMT is going to be found useful, it may have a place in selected cases who may not be willing for Radical cystectomy for MIBC.

    We have some dedicated Uro Oncologists in our group and their opinion would be worth having.

    With warm Regards,



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