Unanswered questions regarding bladder preservation after NAC

Among the discussions held as part of the scientific program at the 41st Annual European Association of Urology Congress in London, United Kingdom, was a debate titled “Bladder preservation post-NAC: Smart strategy or risky business?” In this video, Bogdana Schmidt, MD, MPH, an assistant professor of urology at the University of Utah Huntsman Cancer Institute in Salt Lake City, offers a candid, measured take on bladder preservation following neoadjuvant chemotherapy (NAC), framing it as a genuinely promising but not yet clinically ready strategy for most patients in 2026.

On the risks, Schmidt's core concern is that the field has not yet resolved the foundational questions needed to make bladder preservation safe in practice. Chief among them is patient selection: Although lower-risk profiles—solitary tumors, absence of carcinoma in situ, no lymphovascular invasion—are intuitively better candidates, clinical trials have enrolled more heterogeneous populations, leaving selection criteria poorly defined. The RETAIN trial, for instance, focused on patients with specific mutations, raising questions about what level of genomic screening should be standard. Beyond selection, surveillance protocols remain unresolved. How frequently should cystoscopy and CT or MRI imaging occur? For how long? When is it appropriate to extend intervals? Circulating tumor DNA is promising for detecting metastatic risk but does not reliably predict local recurrence. Urinary tumor DNA may be more relevant, but questions of which assay, timing relative to bladder interventions, and test reliability remain unanswered. Schmidt's bottom line: The approach is exciting, but not yet ready for routine clinical use.

On counseling patients who want to avoid cystectomy, Schmidt points to trimodality therapy as the established bladder-preserving option, supported by longer-term data and propensity-matched analyses showing outcomes comparable to cystectomy in selected patients. The newer question—whether patients receiving more potent NAC regimens incorporating immunotherapy can simply forgo cystectomy and enter surveillance—remains unanswered for average-risk patients. Current data suggest 30% to 60% of such patients will recur, making it a significant gamble that requires transparent, individualized counseling.