Partial cystectomy (PC) remains an underutilized bladder-sparing approach for carefully selected patients with muscle-invasive bladder cancer (MIBC). While radical cystectomy (RC) remains the standard of care, it is associated with substantial morbidity and functional impact. For patients with small, solitary, cT2 lesions and no carcinoma in situ, PC may be an alternative—particularly if performed alongside neoadjuvant chemotherapy (NAC) and pelvic lymph node dissection (PLND). However, contemporary data suggest that these standard adjunct therapies are infrequently incorporated into PC regimens.
Study Methodology:
In our recent study, we conducted a retrospective cohort analysis of 2,832 patients with cT2-4N0M0 bladder cancer who underwent PC between 2004 and 2019 using the National Cancer Database. We evaluated trends in NAC and PLND utilization, predictors of their receipt, and the impact of these modalities on overall survival (OS). Multivariable Cox proportional hazards and logistic regression models were used to adjust for clinical and demographic confounders.
Key Findings:
- Survival Benefit: Median OS for patients undergoing PC alone was 43.9 months. However, this improved significantly with the addition of NAC and PLND, with median OS not reached in patients who received both. A lymph node yield ≥10 was associated with the most pronounced survival benefit (aHR 0.586, P<0.001).
- Pathologic Response: NAC was associated with improved pathologic downstaging, including a tenfold increase in complete pathologic responses (28.6% vs. 3.7%) and a decrease in positive margin rates (9.3% vs. 16.2%).
- Underutilization and Disparities: Only 8.1% of PC patients received NAC, and 54.3% underwent PLND. Women were significantly less likely to receive PLND (OR 0.719, P=0.005), highlighting a potential gender disparity. Academic centers were more likely to incorporate both NAC and PLND.
- Temporal Trends: The use of NAC and PLND increased over time, particularly after 2016, aligning with the updated AUA/ASCO/ASTRO/SUO guidelines. Yet, even in 2019, only ~6% of PC patients received both NAC and PLND.
Our findings underscore the importance of multimodal therapy in PC. They are in line with recent data from Herr et al., who published a 20-year follow-up data on 63 patients with cT2N0M0 MIBC treated with NAC and PC at Memorial Sloan Kettering Cancer Center. In that prospective cohort, 83% preserved their bladder and 92% were alive without disease recurrence at long-term follow-up (median: 15.8 years). Thus, when appropriately combined with NAC and PLND, PC may offer oncologic outcomes comparable to those of RC in well-selected patients. These results support expanding PC as a bladder-preserving strategy—but only if delivered with guideline-concordant care.
Limitations include the retrospective design, lack of granular surgical data, and inability to capture regimen-specific NAC details. Future directions include prospective validation, investigating disparities in bladder cancer care, and defining benchmarks for quality indicators, such as nodal yield, for this select population.
Conclusion
PC is a viable treatment option for a subset of MIBC patients, but only when paired with NAC and PLND. As interest in bladder preservation grows, our study contributes to the evidence base supporting optimized PC as a curative-intent strategy and highlights the need for improved adherence to national guidelines to enable further investigation and refinement.
Written by: Ryan M. Antar,1 Vincent E. Xu,1 Christian M. Farag,1 Jack Lucero,1 Arthur Drouaud,1 Vinaik Sundaresan,2 Olivia F. Gordon,1 Sarah Azari,1 Michael Wynne,1 Armine K. Smith,3 Michael J. Whalen1
- Department of Urology, George Washington University School of Medicine, Washington, DC, USA.
- Yale School of Medicine, New Haven, CT, USA.
- The James Buchanan Brady Urologic Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.