Is it time for urologists to begin to rethink radical cystectomy and begin to explore trimodality therapy? Maybe — maybe not — it depends on who you ask. Let’s go over a few things first, though, before we jump right in.
(TMT) Trimodality Therapy is not some radical new line of treatment. The “Tri” stands for three “modalities” of treatment: chemotherapy, radiotherapy, and surgery. And again, while nothing new, the treatments used in combination to fight Invasive Bladder Cancer are a course of treatment that allows the patient to keep their bladder rather than have it removed.
(RC) Radical Cystectomy is typically the removal of the entire bladder, lymph nodes in proximity to the bladder, part of the urethra, and any organ tissue in proximity that does or could have cancerous cells.
For women, it can — but not always — entail uterus, ovaries, fallopian tubes, and part of the vagina is being removed.
For men, it can — but not always — entail prostate, seminal vesicles, part of the vas deferens being removed.
If your urethra was not removed, resulting surgery will require a bladder substitution reservoir “neobladder” inside the body to act as your continent reservoir, and urine will pass much the same way as before.
If your urethra was removed, then you will require a continent diversion reservoir with stoma “urostomy” with a catheter outside the body.
Some doctors believe trimodality therapy should always be considered first and cystectomy reserved only for patients who cannot or will not go through the trimodality therapy for whatever reason.
Recently data was published comparing the two approaches in terms of the survival rate over a five-year period. The survival rate for TMT patients was 57%, and the survival rate for RC patients was 51-53%, depending on whether the RC patients received chemotherapy or not. This shows a favorable outcome of 5% for TMT and the patient keeps their bladder. Major guidelines still recommend cystectomy as the gold-standard treatment for bladder cancer. A cystectomy after the undergoing TMT has a higher complication rate than a cystectomy with no TMT.
More research needs to be conducted on TMT, but in some cases, it can be an option to RC, though not every time.