Treatment of Nonmetastatic Muscle-Invasive Bladder Cancer

Publication Date: August 10, 2017
Last Updated: March 14, 2022


Initial patient evaluation and counseling

Before treatment consideration, a full history and physical examination should be performed, including an examination under anesthesia, at the time of transurethral resection of bladder tumor (TURBT) for a suspected invasive cancer. (CP)
Before muscle-invasive bladder cancer 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). (CP)
An experienced genitourinary pathologist should review the pathology of a patient when variant histology is suspected or if muscle invasion is equivocal (eg, micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, extensive squamous or glandular differentiation). (CP)
Before treatment, clinicians should counsel patients regarding complications and the implications of treatment on quality of life (eg, impact on continence, sexual function, fertility, bowel dysfunction, metabolic problems). (CP)
For patients with newly diagnosed muscle-invasive bladder cancer, 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. (CP)


Neoadjuvant and adjuvant chemotherapy

Using a multidisciplinary approach, clinicians should offer cisplatin-based neoadjuvant chemotherapy to eligible patients undergoing radical cystectomy, before cystectomy. (EB, B, S)
Clinicians should not prescribe carboplatin-based neoadjuvant chemotherapy for clinically resectable stage cT2-T4aN0 bladder cancer. Patients ineligible for cisplatin-based neoadjuvant chemotherapy should proceed to definitive locoregional therapy. (EO)
Clinicians should perform radical cystectomy as soon as possible after a patient’s completion of and recovery from neoadjuvant chemotherapy. (EO)
Eligible patients who have not received cisplatin-based neoadjuvant chemotherapy and have non–organ-confined (pT3/T4 and/or N+) disease at cystectomy should be offered adjuvant cisplatin-based chemotherapy. (EB, C, M)

Radical cystectomy

Clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy for surgically eligible patients with resectable nonmetastatic (M0) muscle-invasive bladder cancer. (EB, B, S)
When performing a standard radical cystectomy, clinicians should remove the bladder, prostate, and seminal vesicles in male patients and should remove the bladder, uterus, fallopian tubes, ovaries, and anterior vaginal wall in female patients. (CP)
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. (EB, C, M)

Urinary diversion

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

Perioperative surgical management

Clinicians should attempt to optimize patient performance status in the perioperative setting. (EO)
Perioperative pharmacologic thromboembolic prophylaxis should be given to patients undergoing radical cystectomy. (EB, B, S)
In patients undergoing radical cystectomy, µ-opioid antagonist therapy should be used to accelerate GI recovery, unless contraindicated. (EB, B, S)
Patients should receive detailed teaching regarding care of urinary diversion before discharge from the hospital . (CP)

Pelvic lymphadenectomy

Clinicians must perform a bilateral pelvic lymphadenectomy at the time of any surgery with curative intent. (EB, B, S)
When performing bilateral pelvic lymphadenectomy, clinicians should remove, at a minimum, the external and internal iliac and obturator lymph nodes (standard lymphadenectomy). (CP)

Bladder-Preserving Approaches

Patient selection

For patients with newly diagnosed nonmetastatic muscle-invasive bladder cancer 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. (CP)
In patients under consideration for bladder-preserving therapy, maximal debulking TURBT and assessment of multifocal disease and carcinoma in situ should be performed. (EB, C, S)

Maximal TURBT and partial cystectomy

Patients with muscle-invasive bladder cancer who are medically fit and consent to radical cystectomy should not undergo partial cystectomy or maximal TURBT as primary curative therapy. (EB, C, M)

Primary radiation therapy

For patients with muscle-invasive bladder cancer, clinicians should not offer radiation therapy alone as a curative treatment. (EB, C, S)

Multimodal bladder-preserving therapy

For patients with muscle-invasive bladder cancer who have elected multimodal bladder-preserving therapy, clinicians should offer maximal TURBT, chemotherapy combined with external beam radiation therapy, and planned cystoscopic re-evaluation. (EB, B, S)
Radiation-sensitizing chemotherapy regimens should include cisplatin or fluorouracil and mitomycin C. (EB, B, S)
After completion of bladder-preserving therapy, clinicians should perform regular surveillance with computed tomography scans, cystoscopy, and urine cytology. (EB, C, S)

Bladder-preserving treatment failure

In patients who are medically fit and have residual or recurrent muscle-invasive disease after bladder-preserving therapy, clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy. (EB, C, S)
In patients who have a non–muscle-invasive recurrence after bladder-preserving therapy, clinicians may offer either local measures, such as TURBT with intravesical therapy, or radical cystectomy with bilateral pelvic lymphadenectomy. (EB, C, M)

Patient Surveillance and Follow-Up


Clinicians should obtain chest imaging and cross-sectional imaging of the abdomen and pelvis with computed tomography or magnetic resonance imaging at 6- to 12-month intervals for 2 to 3 years and then may continue annually. (EO)

Laboratory values and urine markers

After therapy for muscle-invasive bladder cancer, patients should undergo laboratory assessment at 3- to 6-month intervals for 2 to 3 years and then annually thereafter. (EO)
After radical cystectomy in patients with a retained urethra, clinicians should monitor the urethral remnant for recurrence. (EO)

Patient survivorship

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

Variant Histology

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

Recommendation Grading




Treatment of Nonmetastatic Muscle-Invasive Bladder Cancer

Authoring Organizations

Publication Month/Year

August 10, 2017

Last Updated Month/Year

June 6, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Target Patient Population

Patients with nonmetastatic muscle-invasive bladder cancer.

Inclusion Criteria

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

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Management, Treatment

Diseases/Conditions (MeSH)

D001749 - Urinary Bladder Neoplasms


bladder cancer, Nonmetastatic Muscle-Invasive Bladder Cancer

Supplemental Methodology Resources

Data Supplement, Evidence Tables


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