ASTRO endorses trimodal bladder preservation as an alternative to cystectomy for selected muscle-invasive disease; most men lose erectile function after curative prostate treatment

The edition in brief

An American Society for Radiation Oncology guideline recommends trimodal therapy — maximal resection followed by radiotherapy with concurrent radiosensitising systemic therapy — as an alternative to radical cystectomy for selected cT2-4aN0M0 muscle-invasive bladder cancer, with multidisciplinary review for every patient, IMRT with daily image guidance, conditional adjuvant radiotherapy after cystectomy for pT3-4, node-positive or margin-positive disease, and bladder-directed palliative radiotherapy. In 13,413 men in the TrueNTH Global Registry, sexual function fell after every curative prostate cancer treatment, by a median 60% after prostatectomy and 40% after brachytherapy, and 64% to 92% reported poor or absent erections at 12 months, while few used sexual aids. The ProBIOPSY Delphi of 34 experts endorsed biparametric or multiparametric MRI and a targeted plus perilesional biopsy scheme for most decisions, with contralateral sampling still needed before focal therapy. A meta-analysis of 3,509 men found thulium fibre and holmium enucleation clinically comparable. In the single-centre ORAKTx trial of 106 transplants, robotic surgery had fewer major complications (13% vs 25%) but the difference was not significant. The practical message: discuss trimodal therapy with every suitable patient with muscle-invasive bladder cancer, and plan sexual rehabilitation before prostate treatment begins.