Bladder preservation approach versus radical cystectomy for high-grade non-muscle-invasive bladder cancer: a meta-analysis

Introduction: Bladder cancer is a common cause of morbidity and mortality worldwide. The primary treatment for intermediate and high-grade non-muscle-invasive bladder cancer (HS-NMIBC) involves the bladder preservation approach (BPA) transurethral resection of bladder tumor (TURBT) followed by intravesical Bacillus Calmette-Guérin (BCG) immunotherapy. For BCG-unresponsive patients, radical cystectomy (RC) is the gold standard. Materials and Methods: A comprehensive literature search was conducted on PubMed, Scopus, and Cochrane Central to identify relevant studies. Eligibility criteria used were patients suffering from HS-NMIBC and studies that exhibited the comparison between the BPA and RC followed by TURBT. All analyses were conducted using Review Manager version 5.4, and the statistical significance level was set at P < 0.05. Results: This systematic review and meta-analysis included five studies. The most prominent outcomes being assessed were overall survival (OS) between BPA and RC at intervals of 2 years, 5 years, and 10 years and cancer-specific mortality (CSM) between BPA and RC at intervals of 2 years and 5 years. OS showed insignificant results at 2 years (RR 0.79, 95%CI 0.95–1.30; P = 0.19), RC favoring OS in 5 years (RR 1.17, 95%CI 1.10–1.24; P <0.00001) and insignificant differences between the two managements in terms of OS for 10 years (RR 1.19, 95% CI 0.87–1.63; P = 0.27). BPA favors CSM in 2 years (RR 0.28, 95%CI 0.23–0.34; P <0.001) and 5 years (RR 0.46, 95%CI 0.40–0.52; P <0.001). Conclusion: Both approaches prevent CSM and progression from HG-NMIBC; bladder preservation with BCG may be a superior strategy when compared to RC. The former approach improves OS notably in the elderly and those with T1G3 tumors. However, RC may still be a preferable alternative for the younger population. Despite this, determining the optimal BPA method remains a challenge and future high-quality studies are needed to verify these findings and provide impactful reviews.