Bladder preservation in the treatment of muscle-invasive bladder cancer (MIBC): a review of the literature and a practical approach to therapy Zachary L. Smith, John P. Christodouleas*, Stephen M. Keefe † , S. Bruce Malkowicz and Thomas J. Guzzo Division of Urology, *Department of Radiation Oncology, and † Department of Medicine, Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA What’s known on the subject? and What does the study add? Bladder preservation therapies for muscle-invasive bladder cancer (MIBC) have been developed to address the needs of two cohorts: patients with severe medical co-morbidities for whom radical cystectomy is too high risk and patients with limited disease who wish to avoid aggressive surgery. There are multiple bladder preservation options, although the trimodal approach of maximal transurethral resection with chemoradiotherapy is the most strongly supported. While outcomes are worse for patients unfit for surgery than those otherwise fit for surgery, bladder preservation approaches still offer curative potential. We present a comprehensive review of the literature and outline a practical approach to bladder preservation therapy for MIBC. This review aims to help urologists easily navigate through the decision tree of therapeutic options. • Radical cystectomy (RC) is associated with considerable morbidity. Aside from the perioperative period, RC with urinary diversion poses great potential for long-term complications and morbidity. • Bladder preservation therapies for muscle-invasive bladder cancer (MIBC) have been developed to address the needs of two cohorts: patients with severe medical co-morbidities for whom a radical surgery is too high risk and patients with limited disease who wish to avoid radical surgery. • The goal of achieving complete response to treatment while maintaining bladder form and function has led to the development of multimodal approaches to this disease. • There are multiple bladder preservation options, although the trimodal approach of maximal transurethral resection with chemoradiotherapy is the most strongly supported. • In medically operable patients (‘fit’ for surgery), there is abundant evidence to support trimodal therapy as an acceptable treatment option for highly selected patients with MIBC with favourable pathological parameters. • While outcomes are worse for medically inoperable patients (‘unfit’ for surgery), bladder preservation approaches still offer curative potential. However, prospective trials comparing the above regimens to RC are still needed to better define their role in the treatment of MIBC. • We present a comprehensive review of the literature and outline a practical approach to bladder preservation therapy for MIBC. Keywords bladder cancer, muscle-invasive, bladder-sparing, bladder preservation, chemotherapy, radiation therapy © 2013 BJU International | 112, 13–25 | doi:10.1111/j.1464-410X.2012.11762.x 13 Review