Muscle invasive bladder cancer and bladder preservation protocols. Where are we?

Radical cystectomy remains as gold standard for treatment of muscle-invasive bladder cancer. Radical cystectomy has a high morbidity and mortality associated even with the new anesthetic and surgical techniques. Some patients are still not candidates for this major surgery. Besides, some patients reject radical cystectomy. Bladder preservation strategies were develop aiming to decrease morbidity and mortality related to major surgery. Bladder preservation allow for improved quality of life and similar oncologic control rates. Bladder preservation has historically been used in 2 clinical scenarios: I) Patients unable to undergo a radical cystectomy due to comorbidities o patients that reject radical cystectomy, and 2) patients that are offered bladder preservation strategies with and oncological safety and curative intent. This is the real scenario for bladder preservation, the first scenario belongs to palliation, not cure. In the current manuscript, we will review the bladder preservation strategies for muscle invasive bladder cancer, specially focusing on trimodal therapy (recommended by international guidelines) and tetramodal therapy.