Against bladder sparing: Surgery

Purpose: The efficacy of bladder preservation strategies for invasive cancer of the bladder are evaluated. Materials and Methods: The literature was reviewed specifically regarding the relative success of bladder preservation therapy compared with total cystectomy. Results: Bladder preservation strategies currently available are substantially inferior to cystectomy for elimination of the existing cancer and prevention of pelvic recurrence (soft tissue after cystectomy or in the bladder after bladder preservation). The best bladder preservation protocols eliminate cancer from the bladder at first evaluation in 10 to 20% and 50 to 80% of patients with T3b and T2 cancers, respectively, while later recurrences in the bladder are seen in 40 to 60%. Cystectomy provides a local failure rate of 10 to 25% for T2 and T3b disease, respectively. In addition, bladder reconstruction with a neobladder after cystectomy minimizes deterioration of quality of life which is the motivating rationale for bladder preservation. Conclusions: While continuing clinical trials of new strategies for bladder preservation are necessary and laudable, clinical practice currently affirms cystectomy, possibly with neobladder formation, as optimal therapy in appropriate patients.