MDCalc Guideline Summary: Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer

When invasive bladder cancer is suspected, a thorough history, physical, and an exam under anesthesia should be done at the time of the tumor resection procedure (TURBT).

Before deciding on treatment, patients need complete staging studies, including imaging of the chest and contrast-enhanced CT or MRI of the abdomen and pelvis (unless contrast is unsafe for them). Bloodwork should include a complete blood count, liver function tests, and kidney function tests.

If the tumor is likely to have unusual features (such as micropapillary, nested, plasmacytoid, neuroendocrine, or sarcomatoid patterns, or significant squamous/glandular differentiation) or if it's unclear whether the muscle layer is invaded, a pathologist specializing in genitourinary cancers should review the pathology.

In patients with variant histology, the evaluation and management of urothelial carcinoma may diverge from the standard recommendations and clinicians should consider the clinical characteristics of the specific patient.

Once a patient is newly diagnosed, all potentially curative treatment paths should be reviewed and weighed against the person's overall health and the tumor-specific characteristic, ideally through a multidisciplinary team. Patients should be counseled about potential complications of treatments and how these may affect their quality of life.

Working through a multidisciplinary team, clinicians should offer cisplatin-based chemotherapy before surgery to eligible patients planning to undergo radical cystectomy.

In patients with clinically resectable stage cT2-T4aN0 bladder cancer, they should not be prescribed carboplatin-based chemotherapy before surgery; when cisplatin is not appropriate, patients should instead proceed to definitive local/regional treatment or a clinical trial.

Radiation therapy alone should not be offered as a curative option for patients with muscle-invasive bladder cancer.

Once a patient completes and recovers from neoadjuvant chemotherapy, radical cystectomy should be performed promptly, ideally within about 12 weeks, unless there's a medical reason to wait longer.

Prior to surgery, clinicians should identify and optimize treatment and management of comorbidities that may affect surgical outcomes (e.g., nutritional statement, smoking).

Patients with non-metastatic, surgically resectable muscle-invasive bladder cancer who are fit for surgery should be offered radical cystectomy with bilateral pelvic lymph node removal.

When a medically fit patient consents to radical cystectomy, doctors shouldn't substitute partial bladder removal or extensive TURBT alone as the main curative treatment.

In a standard curative cystectomy, male patients should have their bladder, prostate, and seminal vesicles removed; female patients should have their bladder removed, with consideration of removal of nearby reproductive organs decided on a case-by-case basis based on disease location and characteristics and need for clean disease margins.

When disease is confined to the organ and doesn't involve the bladder neck, urethra, or prostate, clinicians should discuss options for preserving sexual function with the patient.

In patients undergoing radical cystectomy, pharmacologic thromboembolic prophylaxis and µ-opioid antagonist therapy (unless contraindicated) should be given in the perioperative period.

Before radical cystectomy, patients should be informed about all urinary diversion options, including ileal conduit, continent cutaneous diversion, and orthotopic neobladder.

For patients getting an orthotopic diversion, clinicians must confirm the urethral margin is cancer-free.

Before leaving the hospital, patients should receive thorough instruction on how to care for their urinary diversion.

Any surgery performed with curative intent must include a bilateral pelvic lymph node removal, removing the external and internal iliac and obturator lymph nodes, at a minimum.

For patients newly diagnosed with non-metastatic muscle-invasive bladder cancer who do not want their bladder removed, as well as those with significant health issues that prevent them from undergoing radical cystectomy, bladder-preserving therapy should be offered when clinically appropriate.

Patients being considered for bladder-preserving therapy should undergo maximal debulking TURBT along with an assessment for multifocal disease or carcinoma in situ (CIS).

Patients with muscle-invasive bladder cancer who choose tri-modality (organ-preserving) therapy should be offered maximal TURBT followed by chemotherapy combined with external beam radiation, with planned cystoscopic follow-up on the same schedule used for high-risk non-muscle-invasive bladder cancer.

When multimodal therapy is used with curative intent, it should include chemotherapy that sensitizes the tumor to radiation.

Patients who did not receive cisplatin-based chemotherapy beforehand and are found to have pT3-4 and/or node-positive disease at cystectomy should be offered cisplatin-based chemotherapy or immunotherapy, while those who did receive cisplatin-based chemotherapy beforehand and have pT2-4 and/or node-positive disease at cystectomy should be offered immunotherapy.

Medically fit patients who have residual or recurrent muscle-invasive disease after bladder-preserving therapy should be offered radical cystectomy with bilateral pelvic lymph node removal.

Patients who have a non-muscle-invasive recurrence after bladder-preserving therapy may be offered either local treatment, such as TURBT with intravesical therapy, or radical cystectomy with bilateral pelvic lymph node removal.

After completing bladder-preserving therapy, patients should undergo regular surveillance including CT scans, cystoscopy, and urine cytology.

Chest imaging and abdominal/pelvic CT or MRI should be performed every 6-12 months for 2-3 years, then annually.

After treatment for muscle-invasive bladder cancer, patients should have lab work done every 3-6 months for 2-3 years, then annually.

Patients who retain their urethra after radical cystectomy should have regular monitoring of the urethral remnant for recurrence.

Clinicians should talk with patients about coping mechanisms after diagnosis and treatment and should recommend consideration of cancer support groups or individual counseling.

To support long-term health and quality of life, patients should be encouraged to adopt healthy habits, like quitting smoking, physical activity, and eating well.