Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer

Publication Date: April 26, 2017

Guideline Statements

Initial Patient Evaluation and Counseling

1. Prior to treatment consideration, a full history and physical exam should be performed, including an exam under anesthesia at the time of transurethral resection of bladder tumor (TURBT) for a suspected invasive cancer. (Clinical Principle, )
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2. Prior to muscle-invasive bladder cancer (MIBC) management, clinicians should perform a complete staging evaluation, including imaging of the chest and cross sectional imaging of the abdomen and pelvis with intravenous contrast if not contraindicated. Laboratory evaluation should include a comprehensive metabolic panel (complete blood count, liver function tests, alkaline phosphatase and renal function). (Clinical Principle, )
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3. An experienced genitourinary pathologist should review the pathology of a patient when variant histology is suspected or if muscle invasion is equivocal (e.g., micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, extensive squamous or glandular differentiation). (Clinical Principle, )
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4. For patients with newly diagnosed MIBC, curative treatment options should be discussed before determining a plan of therapy that is based on both patient comorbidity and tumor characteristics. Patient evaluation should be completed using a multidisciplinary approach. (Clinical Principle, )
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5. Prior to treatment, clinicians should counsel patients regarding complications and the implications of treatment on quality of life (e.g., impact on continence, sexual function, fertility, bowel dysfunction, metabolic problems). (Clinical Principle, )
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Treatment


Neoadjuvant/Adjuvant Chemotherapy

6. Utilizing a multidisciplinary approach, clinicians should offer cisplatin-based NAC to eligible radical cystectomy patients prior to cystectomy. (Strong, B)
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7. Clinicians should not prescribe carboplatin-based NAC for clinically resectable stage cT2-T4aN0 bladder cancer. Patients ineligible for cisplatin-based NAC should proceed to definitive locoregional therapy. (Expert Opinion, )
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8. Clinicians should perform radical cystectomy as soon as possible following a patient's completion of and recovery from NAC. (Expert Opinion, )
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9. Eligible patients who have not received cisplatin-based NAC and have non-organ confined (pT3/T4and/or N+) disease at cystectomy should be offered adjuvant cisplatin- based chemotherapy. (Moderate, C)
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Radical Cystectomy

10. Clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy for surgically eligible patients with resectable non-metastatic (M0) MIBC. (Strong, B)
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11. When performing a standard radical cystectomy, clinicians should remove the bladder, prostate, and seminal vesicles in males and should remove the bladder, uterus, fallopian tubes, ovaries, and anterior vaginal wall in females. (Clinical Principle, )
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12. Clinicians should discuss and consider sexual function preserving procedures for patients with organ-confined disease and absence of bladder neck, urethra, and prostate (male) involvement. (Moderate, C)
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Urinary Diversion

13. In patients undergoing radical cystectomy, ileal conduit, continent cutaneous, and orthotopic neobladder urinary diversions should all be discussed. (Clinical Principle, )
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14. In patients receiving an orthotopic urinary diversion, clinicians must verify a negative urethral margin. (Clinical Principle, )
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Perioperative Surgical Management

15. Clinicians should attempt to optimize patient performance status in the perioperative setting. (Expert Opinion, )
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16. Perioperative pharmacologic thromboembolic prophylaxis should be given to patients undergoing radical cystectomy. (Strong, B)
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17. In patients undergoing radical cystectomy μ-opioid antagonist therapy should be used to accelerate gastrointestinal recovery, unless contraindicated. (Strong, B)
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18. Patients should receive detailed teaching regarding care of urinary diversion prior to discharge from the hospital. (Clinical Principle, )
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Pelvic Lymphadenectomy

19. Clinicians must perform a bilateral pelvic lymphadenectomy at the time of any surgery with curative intent. (Strong, B)
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20. When performing bilateral pelvic lymphadenectomy, clinicians should remove, at a minimum, the external and internal iliac and obturator lymph nodes (standard lymphadenectomy). (Clinical Principle, )
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Bladder Preserving Approaches


Patient Selection
21. For patients with newly diagnosed non-metastatic MIBC who desire to retain their bladder, and for those with significant comorbidities for whom radical cystectomy is not a treatment option, clinicians should offer bladder preserving therapy when clinically appropriate. (Clinical Principle, )
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22. In patients under consideration for bladder preserving therapy, maximal debulking TURBT and assessment of multifocal disease/carcinoma in situ should be performed. (Strong, C)
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Maximal Turbt and Partial Cystectomy
23. Patients with MIBC who are medically fit and consent to radical cystectomy should not undergo partial cystectomy or maximal TURBT as primary curative therapy. (Moderate, C)
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Primary Radiation Therapy
24. For patients with MIBC, clinicians should not offer radiation therapy alone as a curative treatment. (Strong, C)
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Multi-Modal Bladder Preserving Therapy
25. For patients with MIBC who have elected multi-modal bladder preserving therapy, clinicians should offer maximal TURBT, chemotherapy combined with external beam radiation therapy, and planned cystoscopic re-evaluation. (Strong, B)
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26. Radiation sensitizing chemotherapy regimens should include cisplatin or 5-fluorouracil and mitomycin C. (Strong, B)
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27. Following completion of bladder preserving therapy, the clinician should perform regular surveillance with CT scans, cystoscopy and urine cytology. (Strong, C)
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Bladder Preserving Treatment Failure
28. In patients who are medically fit and have residual or recurrent muscle-invasive disease following bladder preserving therapy, clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy. (Strong, C)
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29. In patients who have a non-muscle invasive bladder cancer (NMIBC) recurrence after bladder preserving therapy, clinicians may offer either local measures, such as TURBT with intravesical therapy, or radical cystectomy with bilateral pelvic lymphadenectomy. (Moderate, C)
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Patient Surveillance and Follow Up

Imaging

30. Clinicians should obtain chest imaging and cross sectional imaging of the abdomen and pelvis with CT or MRI at 6-12 month intervals for 2-3 years and then may continue annually. (Expert Opinion, )
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Laboratory Values and Urine Markers

31. Following therapy for MIBC, patients should undergo laboratory assessment at three to six month intervals for two to three years and then annually thereafter. (Expert Opinion, )
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32. Following radical cystectomy in patients with a retained urethra, clinicians should monitor the urethral remnant for recurrence. (Expert Opinion, )
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Patient Survivorship

33. Clinicians should discuss with patients how they are coping with their bladder cancer diagnosis and treatment and should recommend that patients consider participating in a cancer support group or consider receiving individual counseling. (Expert Opinion, )
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34. Clinicians should encourage bladder cancer patients to adopt healthy lifestyle habits, including smoking cessation, exercise, and a healthy diet to improve long-term health and quality of life. (Expert Opinion, )
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Variant Histology

35. In patients diagnosed with variant histology, clinicians should consider unique clinical characteristics that may require divergence from standard evaluation and management for urothelial carcinoma. (Expert Opinion, )
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Recommendation Grading

Disclaimer

Overview

Title

Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer

Authoring Organizations

Publication Month/Year

April 26, 2017

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This multi-disciplinary, evidence-based guideline for clinically non-metastatic muscle-invasive bladder cancer focuses on the evaluation, treatment, and surveillance of muscle-invasive bladder cancer guided toward curative intent.

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital, Operating and recovery room, Outpatient, Radiology services

Intended Users

Radiology technologist, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D011878 - Radiotherapy, D001749 - Urinary Bladder Neoplasms, D000072281 - Lymphadenopathy, D015653 - Cystectomy

Keywords

bladder cancer, Non-Metastatic cancer, Bladder Preservation

Source Citation

Chang, S. S., Bochner, B. H., Chou, R., Dreicer, R., Kamat, A. M., Lerner, S. P., Lotan, Y., Meeks, J. J., Michalski, J. M., Morgan, T. M., Quale, D. Z., Rosenberg, J. E., Zietman, A. L., & Holzbeierlein, J. M. (2017). Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline. The Journal of urology, 198(3), 552–559. https://doi.org/10.1016/j.juro.2017.04.086

Methodology

Number of Source Documents
331
Literature Search Start Date
January 1, 1990
Literature Search End Date
May 18, 2020