Current State of Bladder Preservation in High Grade Non-Muscle Invasive Bladder Cancer and Localized Muscle Invasive Bladder Cancer.

Purpose of review: In recent years, new, effective bladder sparing techniques have emerged as favorable options for patients with BCG-unresponsive high-grade non-muscle-invasive bladder cancer (NMIBC) and localized muscle-invasive bladder cancer (MIBC), leading to a paradigm shift from the traditional radical cystectomy in clinical practice. Our aim is to examine the evolution of these techniques, summarize the current evidence, and shed light on the future of these treatment options.

Recent findings: Bladder preservation techniques offer a patient-centered approach while also demonstrating non-inferiority to radical cystectomy in terms of survival outcomes for both NMIBC and MIBC patients. Approved novel therapies, including systemic pembrolizumab and intravesical agents such as nadofaragene, nogapendekin alfa inbakicept, and cretostimogene grenadenorepvec, have shown promising results for BCG-unresponsive NMIBC patients. For carefully selected MIBC patients, Trimodal Therapy (TMT) remains an effective alternative. However, the consensus on the addition of neoadjuvant chemotherapy to TMT and the choice of radio-sensitizing chemotherapy / fractionation schedule of radiation therapy is still under investigation. Additionally, immunotherapy in BCG-naïve patients and as part of concurrent chemoradiotherapy regimens in MIBC patients offers favorable early results. Bladder preservation is a feasible and increasingly preferred alternative in certain NMIBC and MIBC patients who are either unfit or unwilling for radical cystectomy. Promising novel therapies, such as immunotherapy, recombinant intravesical therapies, and antibody-drug conjugates are emerging as potential alternatives. These therapies aim to achieve good oncological outcomes while maintaining quality of life, providing an alternative to the decades long standard of care.