Following high response rates to systemic therapies like EV Pembro, using radiation for bladder preservation is now questioned. It may constitute overtreatment by radiating a now cancer-free organ, while providing no benefit for the systemic micrometastases that are the primary driver of mortality.

For bladder cancer patients with micrometastatic disease, the standard cystectomy requires a significant delay for the operation and recovery. This window may allow unseen metastases to progress, suggesting that upfront, effective systemic therapy is more critical for survival than immediate major surgery.

During the consensus meeting, patient advocates successfully argued for a highly robust definition of "event-free survival." The final definition counts not just cancer recurrence, but also the need for any additional standard-of-care treatment—including intravesical therapy—as an "event," reflecting the patient's perspective on what constitutes a successful outcome.

Despite strong data favoring pre-surgical systemic therapy, a surgeon argues that many patients will continue to undergo surgery first. This is due to real-world factors like surgeons being the point of diagnosis, urgent symptoms requiring rapid intervention, and patient preferences to have the tumor removed immediately.

Historically, bladder-sparing options were primarily for patients unfit for radical cystectomy. Now, with advances in surgical techniques and perioperative care, fewer patients are deemed truly ineligible for surgery. This shift means new bladder-sparing strategies are being developed for a much broader patient population.

With highly effective neoadjuvant therapies now available, the surgeon's role in muscle-invasive bladder cancer is evolving. They are moving from being the primary decider and treater to being a key manager of a 'perioperative bundle,' where their first goal is often to get patients to medical oncology for systemic treatment.

High relapse rates (~70%) in surgery-alone arms of recent trials suggest most patients with muscle-invasive bladder cancer (MIBC) already have micrometastatic disease. This reframes the disease, prioritizing early systemic therapy over immediate surgery to achieve control and potential cure.

Expert consensus shows a major paradigm shift: perioperative systemic therapy (like EV-Pembro, scoring 2.9) is the undisputed standard for muscle-invasive bladder cancer. Approaches starting with cystectomy alone now score below 1.8, formally branding them as inferior options.

With pathologic complete response rates approaching 67% in patients completing neoadjuvant EV-Pembro, a majority of cystectomies are now removing cancer-free bladders. This creates an ethical and clinical imperative to rapidly launch prospective trials to validate bladder preservation strategies and avoid overtreatment.