The challenge of bladder preservation in muscle invasive bladder cancer: key concepts and future directions

PURPOSE OF REVIEW: Bladder preservation strategies for muscle-invasive bladder cancer (MIBC) are gaining renewed interest as advances in systemic therapy, imaging, and molecular biomarkers challenge the historical primacy of radical cystectomy. This review is timely given increasing rates of clinical and pathological complete response with contemporary neoadjuvant regimens and the growing exploration of response-adapted approaches, including active surveillance. RECENT FINDINGS: Trimodal therapy has been an established bladder-preserving option for carefully selected patients, with long-term oncologic outcomes comparable to radical cystectomy in selected cohorts, though randomized comparisons are lacking. Intensified neoadjuvant strategies incorporating immunotherapy and antibody-drug conjugates have substantially improved oncological outcome and pathological complete response rates, expanding the population potentially eligible for bladder preservation. Concurrently, advances in multiparametric MRI, molecular subtyping, and liquid biopsy technologies have improved response assessment and risk stratification, although lack of standardization and prospective validation limits routine implementation. Early-phase trials suggest that active surveillance after clinical complete response may be feasible in highly selected patients, but long-term safety remains uncertain. SUMMARY: Bladder preservation in MIBC is evolving toward a response-adapted paradigm that integrates novel systemic therapy, multimodal restaging, and patient-centred outcomes.