Tholomier Côme, Souhami Luis, Kassouf Wassim
Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada.
Department of Radiation Oncology, McGill University, McGill University Health Centre, Montréal, Québec, Canada.
Transl Androl Urol. 2020 Dec;9(6):2920-2937. doi: 10.21037/tau.2020.02.10.
Bladder-sparing protocols (BSP) have been gaining widespread popularity as an attractive alternative to radical cystectomy (RC) for muscle-invasive bladder cancer. Unimodal therapies are inferior to multimodal regimens. The most promising regimen is trimodal therapy (TMT), which is a combination of maximal transurethral resection of bladder tumor (TURBT), radiotherapy, and chemotherapy. In appropriately selected patients (low volume unifocal T2 disease, complete TURBT, no hydronephrosis and no carcinoma-in-situ), comparable oncological outcomes to RC have been reported in large retrospective studies, with a potential improvement in overall quality of life (QOL). TMT also offers the possibility for definitive therapy for patients who are not surgically fit to undergo RC. Routine biopsy of previous tumor resection is recommended to assess response. Prompt salvage RC is required in non-responders and for recurrent muscle-invasive disease, while non-muscle-invasive recurrence can be managed conservatively with TURBT +/- intravesical BCG. Long-term follow-up consisting of routine cystoscopy, urine cytology, and cross-section imaging is required. Further studies are warranted to better define the role of neoadjuvant or adjuvant chemotherapy in the setting of TMT. Finally, future research on predictive markers of response to TMT and on the integration of immunotherapy in bladder sparing protocols is ongoing and is highly promising.
膀胱保留方案（BSP）作为肌肉浸润性膀胱癌根治性膀胱切除术（RC）的一种有吸引力的替代方案，已越来越受到广泛欢迎。单一疗法不如多模式治疗方案。最有前景的方案是三联疗法（TMT），它是膀胱肿瘤最大经尿道切除术（TURBT）、放疗和化疗的联合。在适当选择的患者（低体积单灶T2期疾病、完全TURBT、无肾积水且无原位癌）中，大型回顾性研究报告了与RC相当的肿瘤学结局，总体生活质量（QOL）可能有所改善。TMT还为那些不适合接受RC手术的患者提供了确定性治疗的可能性。建议对先前肿瘤切除术进行常规活检以评估反应。无反应者和复发性肌肉浸润性疾病需要及时进行挽救性RC，而非肌肉浸润性复发可通过TURBT +/-膀胱内卡介苗进行保守治疗。需要进行包括常规膀胱镜检查、尿液细胞学检查和横断面成像在内的长期随访。有必要进一步研究以更好地确定新辅助或辅助化疗在TMT中的作用。最后，关于TMT反应预测标志物以及免疫疗法在膀胱保留方案中的整合的未来研究正在进行中，且前景非常广阔。
