A shift towards bladder and kidney preservation
Bladder and kidney preservation strategies are crucial for maintaining patients’ quality of life. Co-chaired by Prof. Morgan Rouprêt (FR) and Dr. Maria Carmen Mir Maresma (ES), the EAU25 Plenary Session on organ-sparing approaches took place this morning, including debates on treatment options.
A shift toward non-invasive staging
In her presentation on ‘Radiological evaluation of MIBC with Bladder MRI’, Dr. Martina Pecoraro (IT) highlighted magnetic resonance imaging (MRI) as a reliable, accurate, and non-invasive tool for local staging. Alongside VI-RADS (Vesical Imaging-Reporting and Data System), a standardised approach for imaging and reporting multiparametric MRI (mpMRI) in bladder cancer, it is possible to define the risk of muscle invasion without invasive procedures.
Dr. Pecoraro: “Results from 29 prospective and well-designed large retrospective bladder MRI and VI-RADS studies enrolling consecutive patients report sensitivity, specificity and AUC of VI-RADS in retrospective study ranged 82-97%, 61.4-97%, and 0.91-0.96, and in prospective study 87-100%, 8.8-99.1%, and 0.83-0.96.”
Dr. Pecoraro highlighted the updated EAU Guidelines released this week for diagnostic work up in patients with confirmed muscle-invasive bladder cancer, “If an MRI is performed for local staging of BCa, it is a strong recommendation that it should be done before TURBT”.
Dr. Peter Black (CA) presented the lecture ‘Localised MIBC: Evaluation of complete response methods – are we ready to spare?’. He stated “The current standard of care for MIBC is morbid. Each modality (neoadjuvant therapy, radical cystectomy, trimodal therapy, urinary diversion) is associated with significant long-term toxicity – we need to de-intensify!”
According to Dr. Black, two critical challenges with active surveillance (AS) after neoadjuvant therapy remain. First, a lack of reliable tools to accurately determine complete response. Second, if persistent disease is missed, it remains unclear whether these patients can be successfully rescued. Dr. Black cites the upcoming NEO-BLAST trial, which will explore the use of MRI, ctDNA, utDNA, and TURBT to identify complete response (CR) and assess ASas a potential alternative.
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Treat the cancer, not the kidney
In a discussion on optimal treatment strategies, Dr. Sara Tornberg (FI) presented a clinical case featuring a small renal mass (SRM) measuring less than 3 cm. The case involved a 75-year-old male patient whose tumour grew from 2 cm to 2.9 cm over one year. A biopsy confirmed clear cell renal cell carcinoma (ccRCC), grade 2-3, setting the stage for a debate on the most effective treatment approach.
“SRM’s are ‘snails and turtles’ in terms of symptom progression and impact on mortality. Active surveillance for an SRM suspicious for cT1a RCC is a safe and durable management strategy”, stated Prof. Phillip Pierorazio (US). “Tumour size is the most reliable indicator of metastatic potential and therefore, the best trigger for intervention.” He recommended AS for tumours between 2-3cm. For tumours measuring 3-4cm, he advised continued AS for 6-12 months, though there is a 30% chance that treatment will be necessary. For tumours over 4cm, treatment should be considered, unless precluding comorbidities.
“Tumour growth rate informs AS. Zero growth = zero risk of metastatic progression. Elevated growth predicts intervention but not poor oncological outcomes if intervention occurs before 4cm. Illness uncertainty and patient preference are strong predictors of AS choice and durability.”
You can watch the full webcast, including a debate based on a case presentation from Dr. Laura Mertens (NL) on low-risk recurrent NMIBC in elderly patient via the EAU25 Resource Centre.