“Neoadjuvant Chemotherapy with Transurethral Resection for Bladder Preservation: 15-year follow-up of the retained bladder”

Bladder preservation is a desired goal for most patients with muscle invasive bladder cancer (MIBC), 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 MIBC, meeting established ideal criteria for bladder preservation, treated initially with systemic therapy and transurethral resection (TUR). 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 1994-2015, with >10 years follow-up. Primary endpoints were bladder-intact survival, local recurrence free survival, and cancer specific survival. 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; 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. 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 versus excess mortality when electing bladder-sparing.