MIBC Expert Report: A comprehensive, multidisciplinary roadmap for navigating a rapidly evolving therapeutic landscape

The Canadian Urological Association (CUA) continues to play a pivotal role in critically evaluating and contextualizing emerging evidence that is reshaping the therapeutic landscape of uro-oncology. While the pathological and clinical staging of muscle-invasive bladder cancer (MIBC) have remained consistent since its 2019 guidelines, significant changes are taking place in the systemic therapy, radiotherapy, and molecular testing areas. Kulkarni et al addresses this new evidence in their 2025 Expert Report on MIBC.¹

Transitioning from scarcity to abundance, the tide of new systemic therapies and combination regimens observed in the advanced and metastatic setting is steadily making its way into the MIBC space. Adjuvant immunotherapy has begun to break away from the “cisplatin-based-chemotherapy-or-nothing” approach in the perioperative setting, whereas both enfortumab vedotin with pembrolizumab and nivolumab with chemotherapy have displaced platinum-based doublet as the best systemic therapy for unresectable locally advanced MIBC.

This ongoing shift makes capturing a definitive treatment landscape in clinical guidelines particularly challenging, as new studies are continually being released, with more on the horizon. At the same time, regulatory approvals and funding processes also follow their own timelines, adding to this challenge. Nonetheless, the authors provide contemporary, evidence-based recommendations while discussing upcoming potential new treatment approvals and highlighting how they could reshape the field in the near future — underscoring the need for clinicians to stay informed.

The Expert Report also addresses evolving data in radiotherapy, such as the role of hypofractionated radiotherapy and the consideration between whole pelvis and bladder-only radiation. More than ever, patients with MIBC are presented with a wide array of therapeutic options — surgery and reconstruction, systemic therapy, radiotherapy — each with its own pros and cons. This underscores how effectively the uro-oncology community has embraced a multidisciplinary approach to move the field forward. It also highlights the personalized nature of each patients’ therapeutic journey, where patients’ preference and reported outcomes are crucial to developing individualized treatment plans. This emphasis on patient-centered care is evident in the current Expert Report and is expected to strengthen as innovations in cancer care continue to accelerate, hopefully providing even more options to clinicians and patients.