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Minerva Urologica e Nefrologica 2020 December;72(6):650-62

DOI: 10.23736/S0393-2249.20.04018-7

Copyright © 2020 EDIZIONI MINERVA MEDICA

language: English

Trimodal therapy in muscle invasive bladder cancer management

Elvira POLO-ALONSO 1, Cynthia KUK 2, 3, Georgi GURULI 4, Asit K. PAUL 5, George THALMANN 5, Ashish KAMAT 6, Eduardo SOLSONA 1, George THALMANN 7, Alfredo I. URDANETA 5, Alexandre R. ZLOTTA 2, 3, Maria C. MIR 1

1 Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain; 2 Division of Urology, Departments of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada; 3 Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada; 4 Division of Urology, Virginia Commonwealth University, Richmond, VA, USA; 5 Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA; 6 Department of Urology, Anderson Cancer Center, Houston, TX, USA; 7 Department of Urology, University Hospital of Bern, Bern, Switzerland



INTRODUCTION: Radical cystectomy (RC) is the current mainstay for muscle-invasive bladder cancer (MIBC). Concerns regarding morbidity, mortality and quality of life have favored the introduction of bladder sparing strategies. Trimodal therapy, combining transurethral resection, chemotherapy and radiotherapy is the current standard of care for bladder preservation strategies in selected patients with MIBC.
EVIDENCE ACQUISITION: A comprehensive search of the Medline and Embase databases was performed. A total of 19 studies were included in a systematic review of bladder sparing strategies in MIBC management was carried out following the preferred reporting items for systematic reviews and meta-analysis (PRISMA).
EVIDENCE SYNTHESIS: The overall median complete response rate after trimodal therapy (TMT) was 77% (55-93). Salvage cystectomy rate with TMT was 17% on average (8-30). For TMT, the 5-year cancer-specific survival and overall survival rates range from 42-82% and 32-74%, respectively. Currently data supporting neoadjuvant or adjuvant chemotherapy in bladder sparing approaches are emerging, but robust definitive conclusions are still lacking. Gastrointestinal toxicity rates are low around 4% (0.5-16), whereas genitourinary toxicity rates reached 8% (1-24). Quality of life outcomes are still underreported.
CONCLUSIONS: Published data and clinical experience strongly support trimodal therapy as an acceptable bladder sparing strategy in terms of oncological outcomes and quality of life in selected patients with MIBC. A strong need exists for specialized centers, to increase awareness among urologists, to discuss these options with patients and to stress the increased participation of patients and their families in treatment path decision-making.


KEY WORDS: Organ sparing treatments; Urinary Bladder; Chemoradiotherapy; Therapeutics; Urinary bladder neoplasms

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