Treatment of muscle invasive and advanced bladder cancer

In muscle-invasive, non-metastatic urothelial carcinoma of the bladder, radical cystectomy is the standard therapy. Despite curative intention, the 5-year survival rate is only about 50%. Cisplatin-based (neo)adjuvant chemotherapy can improve oncological outcomes. In the metastatic stage, therapy is palliative; patients who are cisplatin-ineligible should receive gemcitabine/carboplatin, or alternatively pembrolizumab or atezolizumab for programmed cell death 1 ligand 1 (PD-L1)-positive tumors. For patients showing stable disease or remission after 4-6 cycles of chemotherapy, maintenance therapy with the PD-L1 antibody avelumab should follow. Patients with progression despite chemotherapy may receive second-line pembrolizumab (alternatively atezolizumab or nivolumab). Chemoimmunotherapy showed no significant or only a small benefit regarding progression-free survival.