Kathryn Gessner, MD, PhD, on the challenges of selecting patients for bladder preservation

In the following interview, conducted at the 2026 American Urological Association Annual Meeting, Kathryn H. Gessner, MD, PhD, discusses the ongoing challenge of identifying appropriate candidates for bladder-preserving trimodal therapy and emphasized the importance of shared decision-making when counseling patients who hope to avoid radical cystectomy. Gessner is an assistant professor of urology at the University of North Carolina, Chapel Hill.

Although international efforts such as the Milan Consensus have established criteria for defining a clinical complete response—including negative biopsy, negative cross-sectional imaging, and negative urine cytology¹—Gessner said clinicians still lack reliable tools to determine which patients truly have no residual bladder cancer. She noted that findings from the Systematic Endoscopic Evaluation trial underscore this limitation, with approximately 25% of patients who appeared disease-free based on cystoscopy and biopsy ultimately found to have residual disease at the time of cystectomy.²

Looking ahead, Gessner said improved biomarkers will be critical for expanding bladder preservation strategies. While the RETAIN trial demonstrated that circulating tumor DNA (ctDNA) was not able to reliably predict local recurrences,³ she expressed optimism that urine tumor DNA assays, though still in early development, may ultimately provide a more accurate method for selecting patients who can safely pursue bladder preservation.

When counseling patients who are motivated to avoid surgery, Gessner stressed that current evidence continues to support radical cystectomy as the standard approach. She noted that the impressive outcomes seen with perioperative enfortumab vedotin plus pembrolizumab have been achieved in clinical trials where patients ultimately underwent cystectomy. As a result, she generally recommends surgery while emphasizing the importance of individualized, shared decision-making that balances patient preferences with the available evidence.

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