Pelvic Organ Preservation in Non–muscle-invasive Bladder Cancer: Less Is More

Bladder cancer is the tenth most common cancer worldwide, and 75% of new diagnoses are non–muscle-invasive bladder cancer (NMIBC) [1]. Treatment is guided by risk stratification, response to bacillus Calmette-Guérin, and patient preference and fitness for surgery. Individuals with very high- or high-risk disease may elect for upfront or delayed radical cystectomy (RC) in the event of intravesical therapy failure [2].

Traditional RC includes removal of the bladder and pelvic reproductive organs to obtain maximal oncological control. This includes the ovaries, fallopian tubes, uterus, and anterior vaginal wall in women, and the prostate and prostatic urethra in men. A continent or incontinent urinary diversion is performed concurrently. RC is associated with high morbidity and profound effects on quality of life and sexual function.

Interest in modifications to the traditional technique to allow for reproductive or pelvic organ–sparing cystectomy (ROSC) has increased as a potential mechanism to reduce surgical morbidity and improve functional outcomes. These modifications may be used to reduce the risk of pelvic floor (PF) and sexual dysfunction in appropriately selected patients without apparent compromise of oncologic outcomes [3].

Approximately 30% of patients who undergo RC for NMIBC are upstaged at the time of surgery, underscoring the importance of clinical staging for appropriate patient selection for organ preservation. Staging includes a thorough transurethral resection, examination under anesthesia, and imaging review. For example, the presence of hydronephrosis and a palpable mass has been associated with occult pelvic organ involvement at the time of RC in women; however, a patient with either of these factors should be categorized as having clinical stage T3, even without muscle invasion on transurethral resection of bladder tumor [2].

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