Mathieu Romain, Lucca Ilaria, Klatte Tobias, Babjuk Marko, Shariat Shahrokh F
aDepartment of Urology, Medical University Vienna, General Hospital, Vienna, Austria bDepartment of Urology, Rennes University Hospital, Rennes, France cDepartment of Urology, Centre hospitalier universitaire vaudois, Lausanne, Switzerland dDepartment of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Prague, Czech Republic eDepartment of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas fDepartment of Urology, Weill Cornell Medical College, New York, New York, USA.
Curr Opin Urol. 2015 Sep;25(5):476-82. doi: 10.1097/MOU.0000000000000203.
Trimodal therapy (TMT) is considered the most effective bladder-sparing approach for muscle-invasive urothelial carcinoma of the bladder (MIBC) and an alternative to radical cystectomy. The purpose of this article was to review and summarize the current knowledge on the equivalence of TMT and radical cystectomy based on the recent literature.
TMT consists of a maximal transuretral resection of the bladder, followed by a concurrent radiotherapy and chemotherapy, limiting salvage radical cystectomy to nonresponder tumors or muscle-invasive recurrence. In large population studies, less than 6% of the patients with nonmetastatic MIBC receive a chemoradiation therapy and this rate is stable. A growing body of evidence exists that TMT provides good oncologic outcomes with low morbidity when compared with radical cystectomy. TMT requires, however, a close follow-up because of the high risk of local recurrence and salvage radical cystectomy in up to 30% of the patients. Salvage radical cystectomy can be performed with adequate results but does not offer the same opportunity of reconstruction and functional outcomes than primary radical cystectomy.
Although radical cystectomy is still the treatment of reference for most of the patients with localized MIBC, TMT represents a reasonable alternative in highly selected patients. Any firm conclusion on the equivalence or superiority of one treatment to the other is still limited by the lack of randomized controlled trials and the heterogeneity of the available literature. Future studies and multidisciplinary approach are mandatory to optimize the patient selection and regimen of TMT.
三联疗法（TMT）被认为是治疗肌肉浸润性膀胱尿路上皮癌（MIBC）最有效的保膀胱方法，也是根治性膀胱切除术的替代方案。本文旨在根据近期文献回顾并总结目前关于TMT与根治性膀胱切除术等效性的认识。
TMT包括最大程度的经尿道膀胱切除术，随后进行同步放化疗，仅对无反应肿瘤或肌肉浸润性复发患者进行挽救性根治性膀胱切除术。在大型人群研究中，不到6%的非转移性MIBC患者接受放化疗，且这一比例稳定。越来越多的证据表明，与根治性膀胱切除术相比，TMT能提供良好的肿瘤学结局且并发症发生率低。然而，由于局部复发风险高，高达30%的患者需要进行挽救性根治性膀胱切除术，因此TMT需要密切随访。挽救性根治性膀胱切除术可以取得较好的效果，但与原发性根治性膀胱切除术相比，重建和功能结局的机会不同。
尽管根治性膀胱切除术仍是大多数局限性MIBC患者的参考治疗方法，但TMT在经过严格筛选的患者中是一种合理的替代方案。由于缺乏随机对照试验以及现有文献的异质性，关于一种治疗方法相对于另一种治疗方法的等效性或优越性的任何确凿结论仍然有限。未来的研究和多学科方法对于优化TMT的患者选择和治疗方案至关重要。
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