Although level I evidence is lacking that radical cystectomy (RC) is superior to bladder-preserving therapy (BPT), RC is still advocated as the recommended treatment in patients with nonmetastatic muscle-invasive bladder cancer (MIBC). This study sought to compare the survival of patients with MIBC treated with BPT versus those treated with RC.

All patients with nonmetastatic MIBC diagnoses were identified via the population-based Netherlands Cancer Registry. Only patients treated with BPT or RC were included. The primary endpoint was 2-year disease-free survival (DFS), defined as time from start of treatment until locoregional recurrence, distant metastasis, or death. The secondary endpoint was overall survival (OS). Inverse propensity treatment weighting (IPTW) was used based on propensity scores to adjust for baseline differences between treatment groups. Survival was analyzed with Kaplan-Meier and Cox proportional hazards models.

A total of 1432 patients were included, of whom 1101 underwent RC and 331, BPT. Median follow-up was 39 months (range, 27-51 months). The IPTW-adjusted 2-year DFS was 61.5% (95% CI, 53.5%-69.6%) with BPT and 55.3% (95% CI, 51.6%-59.1%) with RC, with an adjusted hazard ratio of 0.84 (95% CI, 0.69-1.05). The adjusted 2-year OS for patients treated with BPT versus RC was 74.0% (95% CI, 67.0%-80.9%) versus 66.0% (95% CI, 62.7%-68.8%), respectively, with an adjusted hazard ratio of 0.80 (95% CI, 0.64-0.98).

There was no statistically significant difference between the 2-year DFS of patients treated with BPT and RC. We propose that both RC and BPT should be offered as a curative treatment option to eligible patients with nonmetastatic MIBC.