Treatment of Muscle-Invasive Bladder Cancer: from Radical Surgery to Perioperative Immunotherapy and Molecular Personalization

Muscle-invasive bladder cancer (MIBC) is one of the most aggressive urologic malignancies and is characterized by a high risk of recurrence and progression even after radical surgical treatment. In recent years, approaches to MIBC treatment have undergone significant transformation due to the emergence of compelling data on the benefits of perioperative immunotherapy, the development of antibody-drug conjugates, refinements in organ-preserving strategies, and the introduction of circulating tumor DNA (ctDNA) as a potential molecular stratification tool. Recent scientific data demonstrate a shift from the predominantly anatomically-based "neoadjuvant chemotherapy → radical cystectomy" model to a perioperative system in which the choice of treatment intensity is gradually linked to tumor biology, the likelihood of response, tolerability of therapy, and the presence of molecular markers of minimal residual disease. ctDNA is gaining particular importance, potentially allowing for the differentiation of patients with high and low risk of recurrence after surgery. At the same time, a new concept of bladder preservation is emerging in carefully selected patients with a significant response to systemic treatment.