MIBC – Will Radical Cystectomy Relegated to History

• 14 Jun 2021 10:05:39 AM
• |Onco Urology

Dear All,

For long Bladder Cancer was being considered as an ‘Orphaned Cancer’ with no substantial progress taking place. But this scenario has changed dramatically with considerable research emanating for Bladder cancer and today it appears that research into our understanding of Molecular Biology of Bladder Cancer has progressed to such an extent even surpassing Researches that are taking place for Prostate and Kidney Cancers.

Radical Cystectomy with Urinary Diversion was the mainstay in the treatment of MIBC for long. Long ago, Willet F Whitmore (considered as father of Urological Oncology) had introduced RT prior to Radical Cystectomy (Short-term Course and Long-term Course). But RT was in its early stage and subsequently a stage evolved where RT was literally abandoned. Advent of Adjuvant Chemotherapy (MVAC) became the treatment of Choice with Radical Cystectomy. Tolerance to the regime was a problem that restricted its usage. Improvements in understanding of the disease along with advances in RT technologies and less toxic Chemo drugs had considerable impact on treatment for MIBC. There were many who advocated Neoadjuvant Chemotherapy along with Radical Cystectomy and claimed better survival though this was questioned by many as well. It was postulated by the proponents of Neoadjuvant Chemo that the stage could be lowered with chemo. Of late Neoadjuvant Chemo with Radical Cystectomy has gained favour rather than Adjuvant Chemo after Radical Cystectomy.

It was at this time that Trimodality treatment for Bladder Preservation came to the fore. Considerable research went into this with many favouring and an equal lot not favouring. The studies on this are voluminous with no definitive outcomes.

Urinary Diversions of various hues are available and are a necessary accompaniment of Radical Cystectomy for MIBC.  The associated Metabolic consequences after Urinary diversions are many and these consequences at times are more problematic than even Radical Cystectomy. Bergman in his book started the chapter on ‘Urinary Diversions’ with a statement that ‘Urinary Diversion is an Operation of Defeatism’. This statement is true even today.

Though the initial ways for Trimodality treatment had its proponents and antagonists, it did not gain popularity. Recent trials with newer drugs especially Immune Checkpoint Inhibitors, Advanced Technologies of RT are paving the way for a resurgence of Trimodality therapy. There are many trials in offing with some providing favourable results. The talk by Andrea Necchi at the recent ASCO Conference on ‘Steps Towards a Bladder Intact Cure for Muscle Invasive Bladder Cancer’ (Extract of the talk provided as PDF) illustrates the various trials now available with a moto ‘Save the Bladder’. Though most of these trials are ongoing, it is clear that in near future, it is possible that Bladder preservation could be possible for MIBC and it is hoped that with these trials gaining fruition, we will come to a stage when we can consider Radical Cystectomy as an obsolete procedure for MIBC. If this is possible with good outcome, then we can save many patients with MIBC and many could live well passing urine per via naturalis. There will come a time when we Urologists will say ‘there was a time Radical Cystectomy used to be performed for Bladder cancer’.

It is hoped that such a time may not be far away.

I am sure there will be many who may not support the views expressed and it is hoped that the Pundits in the field will express their opinions.

With warm Regards,

Venu

Comments(1)

• 

  Dr. Roy Chally

  15 Jun 2021 12:26:10 PM

  As you said, only pandits can comment on these trials. A day will certainly come when Surgery for all cancers will not be first choice. The bladder preservation protocols we followed earlier, did not yield good results in a study done in Calicut medical College.  

    For me two interesting observations 

  In bladder biopsy, in addition to histology, testing for genetic tumour markers is becoming a routine before initiating therapy. 

  Does this have any role in treatment protocol. 

  mpMRI of bladder is used to assess the response to treatment. If the report is negative for cancer can we skip biopsy?