The UroOnc Minute: Cystectomy vs Bladder-Sparing Therapy, with Mary Beth Westerman, MD, FACS

Welcome back to The UroOnc Minute!

In this episode of The UroOnc Minute, recorded at the 2026 American Urological Association Annual Meeting in Washington, DC, host Adam B. Weiner, MD, sits down with Mary Beth Westerman, MD, FACS, an associate professor of urology at the University of North Carolina School of Medicine in Chapel Hill, to discuss the landmark CISTO trial (NCT03933826)—a large pragmatic study examining patient-reported outcomes among individuals with high-risk non–muscle invasive bladder cancer (NMIBC) who underwent either bladder-sparing therapy or radical cystectomy.¹

Westerman opens by framing the clinical challenge: Although current guidelines recommend cystectomy for very high-risk NMIBC—including patients with recurrent T1 disease after BCG induction or those with variant histology—many patients are reluctant to pursue surgery, and the proliferation of intravesical therapies has made bladder preservation an increasingly available alternative. Against this backdrop, the CISTO trial, designed by John L. Gore, MD, MS, and Angie B. Smith, MD, MS, using the Patient-Centered Outcomes Research Institute patient-centered research mechanism, set out to answer a question that a conventional randomized controlled trial could never ethically address: Do patients who retain their bladders fare better than those who undergo cystectomy?

The trial enrolled more than 500 patients across 36 academic sites. Eligible participants had recurrent high-grade disease and prior BCG exposure, without the constraint of strict FDA response criteria. Approximately 380 patients pursued bladder-sparing therapy, whereas the remainder elected cystectomy. The primary end point was physical functioning at 12 months, with the investigators hypothesizing that bladder preservation would confer a quality-of-life advantage. The results, however, proved surprising: There was no difference in physical functioning between the 2 groups at one year. Moreover, several outcomes favored the cystectomy cohort, with those patients reporting better health-related quality of life, improved physical functioning scores, and lower rates of anxiety and depression. The only domains in which bladder-sparing therapy held an advantage were bowel and sexual health.

Westerman draws several practical lessons from these findings for the general urology community. She emphasizes the importance of initiating cystectomy conversations early in the treatment course—before patients have exhausted multiple lines of intravesical therapy—and underscores that outcomes after cystectomy are better than many patients and clinicians assume. She also highlights the oncologic stakes involved: Patients with recurrent T1 disease are at meaningful risk of understaging and adverse oncologic outcomes, reinforcing the guideline-supported role of cystectomy in this population.

Looking ahead, Westerman situates the CISTO findings within a broader question facing the field: How much intravesical therapy is enough? She anticipates that baseline bladder function and quality of life will become more central to counseling and decision-making, helping guide the timing of surgical intervention. Emerging bladder-sparing modalities, including tumor-directed radiation protocols, may eventually expand options for appropriate patients—but the CISTO data make clear that cystectomy, when offered early and in the right clinical context, should not be viewed as a last resort.

REFERENCE

1. Gore JL, Wolff EM, Nash MG, et al; CISTO Collaborative. Radical cystectomy versus bladder-sparing therapy for recurrent high-grade non-muscle invasive bladder cancer: results from the comparison of intravesical therapy and surgery as treatment options (CISTO) study. J Urol. 2025;213(5S2):e3. doi:10.1097/01.JU.0001111604.90306.91.05