In the United States, urothelial carcinoma of the bladder is the second most common malignancy of the genitourinary tract, and the second most common cause of death of all genitourinary tumors. An estimated 79,000 new cases of bladder cancer and over 16,800 deaths from bladder cancer were expected in 2016 in the United States. Approximately three-fourths of patients present with non-muscle-invasive tumors, while 20% to 40% will either present with or progress to high-grade, muscle-invasive disease. These cancers are highly lethal and are the cause of death in the vast majority of patients within two years of diagnosis without aggressive treatment. Approximately 70% of patients present with localized disease, while 33% have regional spread and 5% have distant metastasis at the time of diagnosis. Radical cystectomy and thorough, meticulous pelvic lymph node dissection is considered standard therapy for high-grade, muscle-invasive bladder cancer and high-grade non-muscle-invasive cancers deemed to be at high risk for progression.1 Cisplatin based peri-operative chemotherapy can be used to improve survival. Management begins with transurethral resection of the bladder tumor (TURBT) with careful attention to histopathologic details such as the depth of invasion, the presence of lymphovascular invasion and/or histologic variants. Subsequent management heavily relies on findings at initial and/or repeat TURBT.
Improvements in anesthesia, surgical technique, and perioperative management have led to a decrease in perioperative morbidity and mortality from surgery. Nevertheless, radical cystectomy with thorough pelvic lymph node dissection remains a complex operation with significant early and late complications. Enhanced recovery protocols have substantially decreased the hospital length of stay and improved the patient experience. The choice of urinary diversion relies heavily on patient factors, surgeon and/or institutional experience and practice. Orthotopic diversion offers excellent functional outcomes in experienced centers and may allow some patients and surgeons to consider radical cystectomy earlier in the disease process when it has the best chance of cure. Bladder sparing protocols include trimodal therapy (TURBT followed by chemo/radiation), partial cystectomy, and ‘radical TURBT’. Single modality chemotherapy or radiation alone should not be recommended for patients with muscle invasive bladder cancer unless no other options are available.
Metastatic bladder cancer should be treated with platinum based chemotherapy and carries a dismal prognosis. Patients who progress following chemotherapy are candidates for immune checkpoint blockade therapy.
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