Balancing potential quality-of-life benefits against the risk of lethal late recurrence with bladder-preserving surgery.

The authors make a clear case for the role of bladder preservation strategies in selected patients with invasive bladder cancer. However, the “zeitgeist” of the article is that these strategies “achieve survival rates similar to those achieved in modern cystectomy series.” The problem with this statement is that the existing database, which consists of large phase ii series, does not permit reliable direct comparisons of outcome because of the vagaries of patient selection. More to the point, it isn’t true. Patients can achieve local control of invasive bladder cancer either by cystectomy or by a bladder preservation approach. However, unlike patients undergoing cystectomy, patients whose bladders are preserved are at risk of late recurrence of invasive cancer in the bladder, even after a complete response (cr). A proportion of these late recurrences are lethal. The authors address this indirectly in their discussion of “Recurrences after Bladder Preservation.” They acknowledge that about one third (14%–43%) of patients will have a local recurrence after a cr and that about half of these recurrences will be invasive. Of these invasive recurrences, the largest published series reported that 50% succumb to metastatic disease. Thus 8%–10% of patients, even when carefully selected, will, when managed with a bladder preservation strategy, suffer a preventable bladder cancer death because of metastasis from invasive late recurrence. These deaths associated with a late bladder recurrence after a cr would have been prevented by cystectomy combined with appropriate neoadjuvant or adjuvant chemotherapy. Patients who have all local disease excised surgically (that is, a surgical cr) have no risk of late recurrence in the bladder, because it has been removed. Bladder preservation strategies do have a role in selected patients, but this approach should be offered in the context of balancing the potential quality-oflife benefits against the risk of lethal late recurrence in the bladder.