Within the categories of T2/T3a urothelial (transitional cell) carcinomas, selected patients may be considered for bladdersparing approaches. The options include aggressive endoscopic transurethral resection (TUR) alone, TUR followed by chemotherapy alone, RT alone, or a combination of chemotherapy and RT. As mentioned, there is not uniform consensus about the applicability of these approaches to the management of T2 tumors.

Bladder-preserving approaches are reasonable alternatives to cystectomy for patients who are medically unfit for surgery and for patients who seek an alternative. The decision as to whether or not to use a bladder-sparing approach is based, in part, on the location of the lesion, the depth of invasion, the size of the tumor, the status of the "uninvolved" urothelium, and the status of the patient (bladder capacity, bladder function and comorbidities). An antecedent history of superficial disease should also be considered. Those with hydronephrosis are poor candidates for bladder-sparing procedures. Metastatic disease must be excluded. Patients in whom a bladdersparing approach is being considered should undergo a cystoscopy, or complete TUR of the tumor as safely as possible, exam under anesthesia and metastatic workup prior to the initiation of therapy. With any of the alternatives to cystectomy, a concern exists over the ability to determine with certainty which bladders that appear to be endoscopically free of tumor (T0), based on a clinical assessment that includes a repeat TURBT, are in fact pathologically free of tumor (pT0). Depending upon the series, upward of 30% to 40% of bladders believed to be free of disease preoperatively after chemotherapy were found to have residual disease at cystectomy. The frequency of residual disease is lower for patients who present with T2 disease but, nevertheless, must be considered when proposing a bladder-sparing approach. When possible, bladdersparing options should be chosen in the context of clinical trials. The guidelines indicate that following maximal TUR, observation, chemotherapy alone, radiation therapy alone or chemotherapy combined with radiation therapy are appropriate treatment options. To date, these approaches have been shown to be beneficial in selected cases. But only chemotherapy combined with radiotherapy has been formally evaluated in prospective randomized comparisons, and the others still be considered investigational. All of the bladder-sparing approaches are based on the principle that an immediate cystectomy need not be performed in all cases and that the decision to remove the bladder can be deferred until the response to therapy is assessed. When chemotherapy combined with radiotherapy is used, a cystoscopy with bladder biopsy is performed midway through the treatment (induction phase), and if disease is observed cystectomy is recommended. For all of the other methods, repeat TUR is performed 2 to 3 months after induction therapy. If persistent disease is observed, salvage cystectomy is recommended when possible.

Routine follow-up to rule out recurrence after completion of therapy involves cystoscopy with or without biopsy every 3 months within the first year, then at increased intervals thereafter. Attention to the bladder as a site of recurrence is only one part of the overall management of patients undergoing bladder preservation, as these individuals remain at risk for recurrence elsewhere in the urothelial tract and distantly. Imaging studies should also be performed as outlined under post-cystectomy follow-up. Continued monitoring of the urothelium, with urinary cytologies at 3-month intervals, is a routine part of the management of all cases in which the bladder is preserved. The follow-up frequency is influenced by the treatment approach, observation or chemotherapy without radiotherapy should be more frequent than when radiation is used.