Treatment of Nonmetastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline


As reported in the Journal of Oncology Practice by Chang et al, for the first time for any type of malignancy, the American Urological Association (AUA), ASCO, American Society for Radiation Oncology (ASTRO), and Society of Urologic Oncology (SUO) have formulated an evidence-based guideline on treatment of nonmetastatic muscle-invasive bladder cancer. The guideline recommendations are based on an expert panel systematic review of the medical literature. The guideline is meant to be used in conjunction with an associated algorithm, available at

Recommendations in most of the guideline domains are summarized/reproduced here. Recommendations on patient surveillance and follow-up and variant histology (nos. 30–35) are not included in the summary here.


Initial Patient Evaluation and Counseling

1. 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 for a suspected invasive cancer.

2. 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 cell count, liver function tests, alkaline phosphatase, and renal function).

3. An experienced genitourinary pathologist should review the pathology of a patient when a variant histology is suspected or if muscle invasion is equivocal (eg, micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, extensive squamous or glandular differentiation).

4. 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.

5. 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).


Neoadjuvant and Adjuvant Chemotherapy

6. Using a multidisciplinary approach, clinicians should offer cisplatin-based neoadjuvant chemotherapy to eligible patients undergoing radical cystectomy, before cystectomy.

7. 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.

8. Clinicians should perform radical cystectomy as soon as possible after a patient’s completion of and recovery from neoadjuvant chemotherapy.

9. Eligible patients who have not received cisplatin-based neoadjuvant chemotherapy and have non–organ-confined (pT3/T4 and/or N1) disease at cystectomy should be offered adjuvant cisplatin-based chemotherapy.

Radical Cystectomy

10. Clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy for surgically eligible patients with resectable nonmetastatic (M0) muscle-invasive bladder cancer.

11. 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.

12. Clinicians should discuss and consider sexual function–preserving procedures for patients with organ-confined disease and the absence of bladder neck, urethra, and prostate (male) involvement.

Urinary Diversion

13. In patients undergoing radical cystectomy, ileal conduit, continent cutaneous, and orthotopic neobladder urinary diversions should all be discussed.

14. In patients receiving an orthotopic urinary diversion, clinicians must verify a negative urethral margin.

Perioperative Surgical Management

15. Clinicians should attempt to optimize patient performance status in the perioperative setting.

16. Perioperative pharmacologic thromboembolic prophylaxis should be given to patients undergoing radical cystectomy.

17. In patients undergoing radical cystectomy, µ-opioid antagonist therapy should be used to accelerate gastrointestinal recovery, unless contraindicated.

18. Patients should receive detailed teaching regarding care of urinary diversion before discharge from the hospital.

Pelvic Lymphadenectomy

19. Clinicians must perform a bilateral pelvic lymphadenectomy at the time of any surgery with curative intent.

20. When performing bilateral pelvic lymphadenectomy, clinicians should remove, at a minimum, the external and internal iliac and obturator lymph nodes (standard lymphadenectomy).

Bladder-Preserving Approaches

Patient Selection

21. 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.

22. In patients under consideration for bladder-preserving therapy, maximal debulking time of transurethral resection of bladder tumor and assessment of multifocal disease and carcinoma in situ should be performed.

Maximal Transurethral Resection of Bladder Tumor and Partial Cystectomy

23. Patients with muscle-invasive bladder cancer who are medically fit and consent to radical cystectomy should not undergo partial cystectomy or maximal time of transurethral resection of bladder tumor as primary curative therapy.

Primary Radiation Therapy

24. For patients with muscle-invasive bladder cancer, clinicians should not offer radiation therapy alone as a curative treatment.

Multimodal Bladder-Preserving Therapy

25. For patients with muscle-invasive bladder cancer who have elected multimodal bladder-preserving therapy, clinicians should offer maximal time of transurethral resection of bladder tumor, chemotherapy combined with external-beam radiation therapy, and planned cystoscopic re-evaluation.

26. Radiation-sensitizing chemotherapy regimens should include cisplatin or fluorouracil and mitomycin C.

27. After completion of bladder-preserving therapy, clinicians should perform regular surveillance with computed tomography scans, cystoscopy, and urine cytology.

Bladder-Preserving Treatment Failure

28. 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.

29. In patients who have a non–muscle-invasive recurrence after bladder-preserving therapy, clinicians may offer either local measures, such as time of transurethral resection of bladder tumor with intravesical therapy, or radical cystectomy with bilateral pelvic lymphadenectomy.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.