Bladder-sparing treatment for muscle-invasive bladder carcinoma using immune checkpoint inhibitors.

Multimodal bladder preservation therapy is already an alternative for patients with muscle-invasive bladder cancer (MIBC) who are unable or unwilling to undergo radical cystectomy. Various bladder-preserving strategies that employ immune checkpoint inhibitors (ICIs) for MIBC have been investigated. There are three common modes of ICI-based bladder preservation therapy, of which the most studied is ICIs combined with chemoradiotherapy. The bladder-preserving strategy of ICIs combined with radiation has been investigated in patients who poorly tolerate chemotherapy. ICIs combined with chemotherapy have also been explored in patients who responded to neoadjuvant therapy with a clinical complete response. All the above-described strategies have shown promising efficacy and manageable safety profiles. However, the value of programmed death-ligand 1 (PD-L1) expression, tumor mutation burden and gene alterations for predicting the efficacy of immune-based bladder preservation therapy is still controversial. There remain some challenges for immune-based bladder preservation therapy, and large-sample randomized trials are needed.