Table 3.

SOGUG-SEOM Recommendations for localized muscle-invasive and advanced urothelial bladder cancer

	LE; GoR
Locoregional disease
Radical cystectomy
RC with pelvic LND is the standard treatment of MIBC cT2-T4aN0M0	IA
Removal of at least ten lymph nodes is recommended for a correct evaluation of lymph node status	IVA
Bladder preservation strategies
In experienced centers a TMT bladder-preserving therapy for MIBC is a reasonable alternative to cystectomy for selected patients who wish to avoid or do not tolerate radical cystectomy	IIB
Radiosensitizing regimens as cisplatin or the combination of 5-FU plus mitomycin C are generally recommended	IIB
Other regimens as cisplatin plus 5-FU, cisplatin plus paclitaxel and low-dose gemcitabine are established alternatives	IIB
Other approaches such as TURBT alone, TURBT followed by chemotherapy or TURBT followed by RT are options for patients who cannot tolerate TMT	IIB
Neoadjuvant treatment
Neoadjuvant cisplatin-based chemotherapy is recommended for patients with T2-4a bladder cancer	IA
Adjuvant treatment
Adjuvant cisplatin-based chemotherapy is recommended in patients with pT3/4 and or pN + disease after RC if no neoadjuvant chemotherapy has been given and who have no contraindication for cisplatin	IA
Follow-up
Follow-up after MIBC should be individualized and adapted to the risk of recurrence. Urine cytology and a CT scan should be done every 3–6 months for at least 3 years, and annually thereafter, with urethral washing and cystoscopy in selected cases	VA
Advanced/metastastic disease
First-line systemic treatment
Cisplatin-based chemotherapy is considered the standard option for first-line metastatic UC. CG is preferred over MVAC and ddMVAC due to its better safety profile	IA
For unfit patients, GCa should be the preferred first-line treatment option	IA
According to the EMA label, pembrolizumab or atezolizumab could be an option in cisplatin ineligible patients with high PD-L1 expression levels	IIIB
Immune checkpoint inhibitors and chemotherapy as maintenance or second-line
Maintenance therapy with avelumab is the standard of care for patients whose disease respond or did not progress after four to six cycles of first-line platinum-based chemotherapy (CG or CaG)	IA
After progression to a first-line platinum-based therapy, PD-1/PD-L1 inhibitors are standard options
Pembrolizumab	IA
Atezolizumab	IIIB
Treatment with vinflunine is an alternative for patients in whom anti PD-1/PD-L1 therapy is not possible	IIB
Treatment after failure to chemotherapy and immune checkpoint inhibitors
For patients progressing after platinum-containing chemotherapy and CPI, enfortumab-vedotin is recommended as standard treatment	IA
For patients progressing after platinum-containing chemotherapy with or without previous CPI, with tumor harboring FGFR mutations or fusions, erdafitinib could be considered	IIIB
Early supportive care is strongly recommended	VA

LE level of evidence; GoR grade of recommendation. RC radical cystectomy. 5FU 5-fluorouracil. LND lymphadenectomy. MIBC muscle-invasive bladder cancer. TMT Trimodal therapy. TURBT transurethral resection of bladder tumor. CG Cisplatin-Gemcitabin. CaG carboplatin-Gemcitabine. PD-1/PD-L1 Programmed Death-1/ Programmed Death-ligand 1. CPI check-point inhibitors. FGFR fibroblast growth factor receptor