Trimodality Therapy Versus Radical Cystectomy for Muscle-invasive Bladder Cancer: A Systematic Review and Meta-analysis of Matched Cohort Studies.

Background And Objective: Radical cystectomy (RC) is the standard treatment for muscle-invasive bladder cancer (MIBC). It is highly invasive and associated with perioperative risks, while bladder-preserving trimodality therapy (TMT) offers a less invasive alternative with preferable quality of life for selected patients. We aimed to compare oncological outcomes of TMT and RC in MIBC patients, and evaluate TMT-specific outcomes.

Methods: In December 2023, PubMed, Scopus, and Web of Science were searched for studies on MIBC patients treated with TMT. Pairwise meta-analyses were conducted to compare overall survival (OS) and cancer-specific survival (CSS) between MIBC patients treated with TMT and RC, utilizing hazard ratios (HRs). We included only matched cohort studies to minimize selection bias. TMT-specific outcomes, such as response, recurrence, and toxicity rates, were pooled separately.

Key Findings And Limitations: Eighty-seven studies (n = 28 218) were identified. No significant differences in OS (HR: 1.05; 95% confidence interval [CI]: 0.78-1.40) and CSS (HR: 1.05; 95% CI: 0.69-1.58) were found for TMT compared with RC. In patients treated with TMT, the complete response was achieved in 74.4% (95% CI: 69.1-79.1), the estimated rate of intravesical recurrence was 23.1% (95% CI: 19.0-27.7), and the rate of grade ≥3 acute toxicity was 11.4% (95% CI: 4.0-28.4).

Conclusions And Clinical Implications: The oncological outcomes of TMT were comparable with those of RC, with an acceptable toxicity profile. TMT appears as a safe and effective treatment for appropriately selected MIBC patients who want to preserve their bladder. However, evidence from high-volume controlled trials is needed.

Patient Summary: Well-selected patients with nonmetastatic muscle-invasive bladder cancer can be treated with "trimodality therapy" to preserve the bladder. So far, the reported outcomes are comparable with those of radical surgery, and we found no signs of excess toxicity.