Neoadjuvant Chemotherapy With Transurethral Resection for Bladder Preservation: 15-Year Follow-Up of the Retained Bladder

PURPOSE: Bladder preservation is a desired goal for most patients with muscle-invasive bladder cancer, although select few are ideal candidates based on established criteria. Heterogenous cohorts with short follow-up hinder assessment of true risks/benefits for ideal candidates. We describe long-term outcomes in patients with muscle-invasive bladder cancer, meeting established ideal criteria for bladder preservation, treated initially with systemic therapy and transurethral resection (TUR). MATERIALS AND METHODS: We conducted an institutional retrospective review of 101 prospectively monitored patients meeting "ideal" criteria for bladder preservation achieving a clinical complete response to cisplatin-based chemotherapy and TUR from 1994 to 2015, with > 10 years of follow-up. Primary end points were bladder-intact survival, local recurrence-free survival, and cancer-specific survival. RESULTS: Fifteen-year risk of death from bladder cancer was 11% (95% CI: 5.8%, 18%), with the competing risk of death from other causes 44% (95% CI: 33%, 54%) and cystectomy risk of 11% (95% CI: 5.9%, 18%). Bladder preservation outcomes were near 40:40:10:10 for death from another cause, alive with an intact bladder, cystectomy, and death from bladder cancer. Of 41 patients alive with their bladder intact, median (IQR) follow-up time was 14 (11, 20) years. One-third relapsed locally, with the probability persisting beyond 10 years, necessitating lifetime surveillance. Our findings may not be generalizable to other settings or to patients not meeting "ideal" criteria. CONCLUSIONS: Bladder preservation with neoadjuvant chemotherapy with TUR is a viable option for select patients meeting established selection criteria. Patients and physicians must consider the probabilities of long-term bladder preservation vs excess mortality when electing bladder-sparing.