If cystectomy is insufficient, what is an urologist to do?

Tumor free survival after radical cystectomy is stage dependent. In addition, other features such as the presence of angioinvasion or micropapillary histology also indicate a poor outcome. Failures of definitive therapy by radical cystectomy occur most frequently at distant sites and appear to result from occult micrometastases present at the time of surgery. These clinical data strongly suggest that radical cystectomy provides insufficient treatment for a group of patients at high risk for tumor recurrence. Multimodal therapy (chemotherapy and surgery) seems to improve outcome in such patients, whether given in a neoadjuvant or adjuvant mode. This increased probability of improved outcome with multimodal therapy, however, is accompanied by an almost certain risk of increased toxicity. The neoadjuvant strategy can deliver systemic chemotherapy more reliably and may permit bladder salvage, but adjuvant therapy permits patient selection based on pathology results. The most critical issue in multimodal therapy is patient selection. The choice of neoadjuvant or adjuvant therapy will depend on clinical circumstances, resources, and patient and physician preferences.