Conservative management of advanced bladder cancer.

Between January 1991 and October 1993, 32 consecutive patients with documented primary bladder tumours invading muscle received 3 cycles of methotrexate, vinblastin, doxorubicin and cisplatin (MVAC). The disease was re-staged by bimanual examination with the patient under anaesthesia, CT scanning and transurethral biopsy or resection. Of the 32 patients 2 underwent total or partial cystectomy and 30 did not, because re-staging showed no residual tumour in 8 (25%), stage T1-2 in 12 (37.5%) and far-advanced tumour in 10 (31.2%). The median follow-up was 2.8 years. Twelve patients with stage T1-2 tumour have required TUR, and cystectomy has not been necessary. Two patients who underwent total/partial cystectomy were all downstaged pathologically. Of the 10 failures 5 patients died of disease and 5 are alive with metastatic disease. The overall survival rate was 84.3% (27 of 32) and was 96.8% for patients with a functioning bladder. The data suggested that this active regimen can clinically induce downstaging in a significant number of patients with primary muscle-infiltrating bladder tumours. Transurethral resection plus MVAC chemotherapy is important for increased curability in patients with advanced bladder cancer.