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Progress is a hallmark of human civilization. Over the past centuries, it became easier, faster and safer to travel from point A to point B, and the choices of transportation are now numerous, making it at times challenging for travelers to make their selection and forcing them to buy guidebooks, research travel websites and sometimes even contact the travel agents. Perhaps sailing was once the only way of crossing the ocean, but with advent of aviation it is no longer the case. Similarly, upfront radical surgeries were once patients’ only hope for cure radical mastectomy for patients with breast cancer, amputation for patients with extremity sarcoma, laryngectomy for patients with laryngeal cancer, radical prostatectomy for patients with prostate cancer, abdominoperineal resection for patients with anal carcinoma. However, over the past 40 years the field of oncology has embraced organ preservation, often, but not always, through randomized clinical trials showing equivalent outcomes with smaller surgeries and adjuvant radiation therapy, or replacement of upfront surgery with definitive chemoradiation therapy, reserving organ extirpation for salvage in case of local recurrences. The management of muscle-invasive bladder cancer (MIBC) is no different (1). Stating that one treatment – such as radical cystectomy – is the best choice for most patients with a particular disease – such as muscle-invasive bladder cancer – is no different from advertising a particular mode of transportation. One treatment never fits all, and the best choice of treatment modality for an individual patient starts with a multi-disciplinary evaluation and inclusion of patients and their caregivers in the decision process. An open discussion of all issues related to radical cystectomy (RC) and reconstruction options on one hand, and tri-modality bladder preservation therapy with chemoradiation (TMT) on the other hand allows for the ultimate informed consent and highest patient satisfaction. Most discussions of bladder preservation for MIBC are centered on two themes – efficacy and toxicity.

Radical Cystectomy is the best choice for most patients with muscle-invasive bladder cancer? Opinion: No