Muscle invasive bladder cancer is best treated by radical cystectomy extended pelvic node dissection and continent ileal neobladder with consideration of either neoadjuvant or adjuvant chemotherapy in higher risk patients
20-25% of bladder cancer is muscle invasive (MIBC). Radical cystectomy is the gold standard, however for unfit patients radical radiotherapy plus chemotherapy is the other option. The gold standard urinary diversion should be continent ileal neobladder once contraindication are excluded. Cystectomy complications are <20-30% (30 day) and mortality is <2%. Local control is excellent with <10% positive surgical margins. The node dissection can go as high as aortic bifurcation +/- presacral. Neoadjuvant CMV has a 5% absolute survival benefit at 5 years and adjuvant a 9% absolute overall survival benefit at 3 years. Follow up should be 3 monthly in the first 2-3 years including CT abdomen pelvis and chest, to detect recurrence promptly. Factors favoring neoadjuvant CMV are pathological – LVI, bulky tumor, micropapillary, inverted growth, small cell and radiologic – perivesical stranding suggesting T3, hydronephrosis, lymphadenopathy and clinical – good ECOG performance, mass on bimanual examination.