Bladder Preservation vs. Cystectomy

How to cite: Petrylak DP. “Bladder Preservation vs. Cystectomy.” Grand Rounds in Urology. August 2026. Accessed Oct 2026. https://grandroundsinurology.com/bladder-preservation-vs-cystectomy/

Summary

In this presentation and discussion from the UroCancer Interdisciplinary Forum 2026, Daniel P. Petrylak, MD, Professor of Medicine and Chief of Genitourinary Oncology, Smilow Cancer Center, Yale University, New Haven, Connecticut, reviews the evolving role of bladder preservation for muscle-invasive bladder cancer, emphasizing that while radical cystectomy remains an effective standard treatment, carefully selected patients may achieve comparable outcomes with bladder-preserving approaches. He notes that cystectomy carries substantial morbidity, particularly in older patients, creating a need for curative alternatives that preserve quality of life without compromising cancer control.

Dr. Petrylak focuses on trimodality therapy consisting of maximal transurethral resection of bladder tumor followed by concurrent chemoradiation and close surveillance. Dr. Petrylak explains that successful bladder preservation requires multidisciplinary collaboration, appropriate patient selection, and the ability to perform salvage cystectomy when necessary.

Dr. Petrylak also discusses response-adapted treatment strategies that incorporate systemic therapy before definitive local treatment. Emerging combinations involving antibody-drug conjugates, immune checkpoint inhibitors, and radiation may further expand bladder preservation, although many approaches remain investigational. Biomarkers, particularly DNA damage repair alterations and circulating tumor DNA, may eventually improve patient selection and guide individualized treatment decisions.

Several ongoing clinical trials are reviewed, including studies evaluating pembrolizumab-based induction therapy, RETAIN-1, HCRN, sasanlimab maintenance, adaptive radiation strategies, and hypofractionated radiation schedules such as the ARCHER trial. Dr. Petrylak highlights that these studies aim to improve convenience, optimize local control, and identify patients who can safely avoid cystectomy while maintaining durable oncologic outcomes.

He concludes that bladder preservation should be considered a carefully selected, response-driven strategy rather than a replacement for radical cystectomy. Future progress will depend on improved biomarkers, standardized surveillance, multidisciplinary care, and prospective clinical trials that better define which patients benefit most from bladder-preserving treatment.