肌層浸潤性膀胱癌保留膀胱的治療策略TNMstagingclassificationfromUICC非浸潤性膀胱癌（表淺性）

Ta,T1,Tis——局限于固有層內(nèi)浸潤性膀胱癌

T2-T4

——腫瘤侵犯至肌層以上

組織病理學(xué)—分期TNMstagingclassificationfromUICC2009(7th)浸潤性腫瘤(T2-4aN0-xM0)Indicationsforcystectomy肌層浸潤性腫瘤♂♀Donotdelaycystectomymorethan3monthssinceitincreasestheriskofprogressionandcancerspecificdeath.ChangSS,etal.Delayingradicalcystectomyformuscleinvasivebladdercancerresultsinworsepathologicalstage.JUrol2003;170:1085保留膀胱的治療

保留膀胱手術(shù)

——TUR：T2a？

——部分切除無手術(shù)條件（全身狀態(tài)、尿道狹窄、憩室等）

強(qiáng)調(diào)綜合治療

5年總生存率45%-73%10年總生存率29%-49%

單純TURBT

TURBT聯(lián)合外放療TURBT聯(lián)合化療TURBT聯(lián)合放、化療

（MultimodalityorTrimodality）

膀胱部分切除聯(lián)合化療目前保留膀胱的治療方法有以下幾種CUAguidelines2014推薦意見：特殊情況下需選擇保留膀胱的治療方法時(shí)，須與患者充分溝通并告知風(fēng)險(xiǎn)，應(yīng)輔以聯(lián)合放、化療，并密切隨訪。CUAguidelines2014EAUguidelines2015EAUguidelines2015BLADDER-SPARINGTREATMENTSFORLOCALISEDDISEASEFeasibilityofRadicalTransurethralResectionasMonotherapyforSelectedPatientsWithMuscleInvasiveBladderCancerEduardoSolsona,etal.JUrol.,2010,184:475Conclusions:Radicaltransurethralbladdertumorresectionisareliabletherapeuticapproachforpatientswithmuscleinvasivebladdercanceraftercompletetumorresectionandwithnegativebiopsiesofthetumorbed.Five-,10-,and15-yrcumulativeDSSrateswere64%,59%,and57%,respectivelyFive-,10-,and15-yrcumulativeOSrateswere52%,35%,and22%,respectivelyT2,Five-,10-,and15-yr74%,67%,and63%T3–4Five-,10-,and15-yr53%,49%,and49%,T2,Five-,10-,and15-yr61%,43%,and28%T3–4Five-,10-,and15-yr41%,27%,and16%72%ofallpatients(78%withT2disease)achievedCRtoinductionchemoradiation.AmongpatientsachievingCR,10-yrratesofnoninvasive,invasive,pelvic(nodalorsidewall),anddistantrecurrenceswere29%,16%,11%,and32%,respectively.Onehundredtwopatients(29%)ultimatelyrequiredacystectomy

—60(17%)immediatelyforlessthanCRand42(12%)inapromptsalvagefashionforrecurrentinvasivetumorsidentifiedduringfollow-upwithclosecystoscopicsurveillance.Mediantimetocystectomyinthesalvagegroupwas1.1yr(95%CI,0.75–1.5).Nopatientrequiredcystectomyresultingfromtreatmentrelatedtoxicity.Outcomes與根治性膀胱全切相比生存率相當(dāng)CMTachievesaCRandpreservesthenativebladderin>70%ofpatients

whileofferinglong-termsurvivalratescomparabletocontemporarycystectomyseries.

Theseresultssupportmodern

bladder-sparingtherapyasaprovenalternativefor

selectedpatients.Bladder-sparingtherapyoffersauniqueopportunityforurologicsurgeons,radiationoncologists,andmedicaloncologiststoworkhand-in-handinatrulymultidisciplinaryeffortforthebenefitofpatientswithinvasiveBCa.ConclusionsFig.7.CRand5-yearOSratesinpatientsreceivingneoadjuvantchemotherapy(NADCT+)ornot(NADCT?).AgrowingbodyofaccumulateddatasuggeststhatTMT(withpromptcystectomyreservedfortumourrecurrenceornonresponders)leadstoacceptableoutcomesandmaythereforebeconsideredareasonabletreatmentoptioninwell-selectedpatients.TMTcanbediscussednotonlyinpatientsunfitforsurgerybutalsoforthosepatientswhohaveMIBCandarenotwillingtoundergosurgery.ConclusionsTheresultsofthisoverviewseemtoindicatethatTMTisabletoproduceexcellent5-yearOSrates,nomatterhowitisdone(continuousorsplit).Nosignificantdifferencein5-yearOSratescouldbeobservedbetweenthetwotreatmentregimens,althoughthecontinuousmayoffersomeadvantagecomparedtosplittreatmentintermsofhigherCRand,likelylowerSCrates.ConclusionsFrom1997–2010,183consecutivepatientswithcT2-4aN0M0bladdercancer(medianage70years,women/men=46/137,T2/3/4a=100/69/14)underwentdebulkingtransurethralresectionfollowedbyLCRT(radiationat40Gytothesmallpelvisconcurrentlywithtwocyclesofi.v.cisplatinat20mg/dayfor5days).(i)EssentiallysolitaryMIBCorintravesicallycircumscribedtumours(≈25%orlessofthebladderinarea,excludingthebladderneckandtrigone);(ii)noinvolvementofbladderneckortrigone;and(iii)clinically,noresidualdiseaseorminimalamountsofnon-invasivediseaseintheoriginalMIBCsiteafterLCRT;otherwise,radicalcystectomy(RC)isrecommended.CriteriaforPCinclude:?Histologicalexaminationofthe46PCspecimensshowedresidualmuscle-invasivediseaseinthree(7%).?Inthe46PCpatients,neitherMIBC,norpelvicrecurrencewasobserved;5-yearCSSandMRFSrateswereboth100%.?Inthecurrentselectivebladder-sparingprotocol,one-thirdofMIBCpatientsmetthePCcriteria;whenpatientsfromthisgroupunderwentPCwithpelviclymphnodedissection,theironcologicaloutcomesweree