We present an overview of the updated 2023 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).
To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.
A broad and comprehensive scoping exercise covering all areas of the MMIBC guidelines has been performed annually since 2017. Searches cover the Medline, EMBASE, and Cochrane Libraries databases for yearly guideline updates. A level of evidence and strength of recommendation are assigned. The evidence cutoff date for the 2023 MIBC guidelines was May 4, 2022.
Patients should be counselled regarding risk factors for bladder cancer. Pathologists should describe tumour and lymph nodes in detail, including the presence of histological subtypes. The importance of the presence or absence of urothelial carcinoma (UC) in the prostatic urethra is emphasised. Magnetic resonance imaging (MRI) of the bladder is superior to computed tomography (CT) for disease staging, specifically in differentiating T1 from T2 disease, and may lead to a change in treatment approach in patients at high risk of an invasive tumour. Imaging of the upper urinary tract, lymph nodes, and distant metastasis is performed with CT or MRI; the additional value of flurodeoxyglucose positron emission tomography/CT still needs to be determined. Frail and comorbid patients should be evaluated by a multidisciplinary team. Postoperative histology remains the most important prognostic variable, while circulating tumour DNA appears to be an interesting predictive marker. Neoadjuvant systemic therapy remains cisplatin-based. In motivated and selected women and men, sexual organ-preserving cystectomy results in better functional outcomes without compromising oncological outcomes. Robotic and open cystectomy have comparable outcomes and should be combined with (extended) lymph node dissection. The diversion type is an individual choice after taking patient and tumour characteristics into account. Radical cystectomy remains a highly complex procedure with considerable morbidity and risk of mortality, although lower rates are observed for higher hospital volumes (>20 cases/yr). With proper patient selection, trimodal therapy (chemoradiation) has comparable outcomes to radical cystectomy. Adjuvant chemotherapy after surgery improves disease-specific survival and overall survival (OS) in patients with high-risk disease who did not receive neoadjuvant treatment, and is strongly recommended. There is a weak recommendation for adjuvant nivolumab, as OS data are not yet available. Health-related quality of life should be assessed using validated questionnaires at baseline and after treatment. Surveillance is needed to monitor for recurrent cancer and functional outcomes. Recurrences detected on follow-up seem to have better prognosis than symptomatic recurrences.
This summary of the 2023 EAU guidelines provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.
The European Association of Urology guidelines panel on muscle-invasive and metastatic bladder cancer has released an updated version of the guideline containing information on diagnosis and treatment of this disease. Recommendations are based on studies published up to May 4, 2022. Surgical removal of the bladder and bladder preservation are discussed, as well as updates on the use of chemotherapy and immunotherapy in localised and metastatic disease.
European urology. 2023 Oct 17 [Epub ahead of print]
J Alfred Witjes, Harman Max Bruins, Albert Carrión, Richard Cathomas, Eva Compérat, Jason A Efstathiou, Rainer Fietkau, Georgios Gakis, Anja Lorch, Alberto Martini, Laura S Mertens, Richard P Meijer, Matthew I Milowsky, Yann Neuzillet, Valeria Panebianco, John Redlef, Michael Rink, Mathieu Rouanne, George N Thalmann, Sæbjørn Sæbjørnsen, Erik Veskimäe, Antoine G van der Heijden
Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. Electronic address: ., Department of Urology, Zuyderland Medisch Centrum, Sittard/Heerlen, The Netherlands., Department of Urology, Vall Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain., Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland., Department of Pathology, Medical University Vienna General Hospital, Vienna, Austria., Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA., Department of Radiation Therapy, University of Erlangen, Erlangen, Germany., Department of Urology and Pediatric Urology, University of Würzburg, Würzburg, Germany., Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland., Department of Urology, Institut Universitaire du Cancer-Toulouse-Oncopole, Toulouse, France; Department of Urology, MD Anderson Cancer Center, Houston, TX, USA., Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands., Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands., Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA., Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France., Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy., Patient Representative, European Association of Urology Guidelines Office, Arnhem, The Netherlands., Department of Urology, Marienkrankenhaus Hamburg, Hamburg, Germany., Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland., Department of Urology, Tampere University Hospital, Tampere, Finland., Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.