To cut or not to cut? Bladder preservation takes center stage
As next-gen therapies deliver striking response rates, experts debate whether cystectomy is still essential—or becoming optional.
The latest generation of neoadjuvant chemotherapy approaches to bladder cancer has transformed bladder preservation from wishful thinking into a topic for serious discussion. Between 55% and 60% of patients undergoing radical cystectomy have no viable tumor in their bladder following neoadjuvant enfortumab vedotin + pembrolizumab or gemcitabine + cisplatin + durvalumab.
“These regimens have, for the first time in three decades, improved survival of patients in a meaningful way,” said Ashish Kamat, MD, MBBS, FACS, endowed professor of urologic oncology and cancer research and director of the Bladder Cancer Support Program at the University of Texas MD Anderson Cancer Center in Houston, Texas. “We should not forget that it is the medical treatment, the drugs, plus the surgical treatment—the removal of the bladder—that has been shown to improve survival. If you try to pick one part of the menu and forget the other components, there’s no guarantee that patients will still live longer.”
The reality that improved survival is associated with the combination of medical plus surgical treatment has not stopped clinicians and patients from questioning the need for cystectomy, given the apparent effectiveness of medical approaches. Clinical trials to assess prognostic factors that may predict survival independent of cystectomy are underway in Europe and the U.S.
Dr. Kamat will moderate a Crossfire debate exploring current thinking around cystectomy and next-generation neoadjuvant regimens at the 2026 AUA Annual Meeting. Bladder Preservation After Neoadjuvant Chemotherapy With Next-Generation Treatments: Can Cystectomy Be Avoided? will highlight the opening plenary session 9:15-9:35 a.m., Friday, May 15, in Hall D of the Walter E. Washington Convention Center.
Amy Luckenbaugh, MD, FACS, assistant professor of urology at Vanderbilt University in Nashville, Tennessee, and Shilpa Gupta, MD, director of genitourinary medical oncology at Taussig Cancer Institute and co-leader of the Genitourinary Oncology Program at Cleveland Clinic in Cleveland, Ohio, will open the session with data for and against bladder preservation. Shahrokh Shariat, MD, professor and chair of urology at the Medical University of Vienna in Austria, and Alejandro Rodriguez, MD, associate professor of urology at the Wake Forest University School of Medicine in Winston-Salem, North Carolina, will offer rebuttals.
“The response rates are so great now, and there is actual data to argue,” Dr. Kamat said. “This is going to be an exciting debate because we don’t have to venture into the theoretical realms of philosophy to suggest that it is better for someone to live with their bladder or not. We have data and clinical trials underway. The whole debate is how we, or even can we, intelligently try to identify patients who would be in the 60% without viable tumor after these more effective treatments. Does that actually mean we avoid removing bladders?”
