Pedro Freitas, MD, on consolidative surgery vs prolonged systemic therapy in MIBC

In an interview at the 2026 Desai Sethi Urology Institute Urology on the Beach meeting, Pedro F.S. Freitas, MD, recapped his talk titled, “Cystectomy Consolidation or Prolonged Systemic Therapy? Controversies in Post-Response MIBC in N+ Disease.” Freitas is a clinical instructor at the Desai Sethi Urology Institute of the University of Miami in Florida.

Freitas began by explaining that the expansion of treatment options in the muscle invasive bladder cancer (MIBC) space, particularly with immunotherapy and antibody drug conjugates, has enabled better response rates. This has led many in the space to consider whether patients who respond to treatment can see further improvement with consolidative surgery, or if they should just continue on with the systemic therapy that is working.

On the consolidative surgery side, Freitas points to 3 main arguments. To start, patients who respond to treatment will tend to be patients who have a more favorable biology, and therefore may have a better prognosis with cystectomy. Further, these patients may have dormant treatment-resistant clones, which may, at some point, become active and spread. Surgery eliminates the source of these future treatment-resistant clones. Lastly, surgery may prevent disease progression in patients who may eventually become incurable.

On the side of continuing with systemic therapy, the argument largely rests on the fact that cystectomy is a morbid procedure. Freitas specifically points to data showing that up to 2/3 of patients will experience at least 1 complication, as well as a low but existent mortality rate.

“For some patients, cystectomy can be challenging and can be potentially life threatening,” he explained. “Because of this, we debate [that] it's not for everybody, but for older and more frail patients, you can make an argument to just keep the systemic therapy, especially if they tolerated it well, so the disease either stop[s] growing or [shrinks].”