Bladder cancer accounts for nearly 600,000 new cases and over 200,000 deaths annually worldwide. Approximately 25% of diagnoses correspond to muscle-invasive disease, and up to 50% of patients undergoing radical cystectomy experience recurrence within the first two years, with a 5-year overall survival reaching 50%-60%. Despite the use of neoadjuvant chemotherapy, clinical trials have failed to attain a considerable reduction in the risk of locoregional recurrence, which remains a major clinical challenge due to the limited and largely ineffective salvage treatment options. In this context, adjuvant radiotherapy (ART) has re-emerged as a potential strategy for reducing locoregional recurrence and improving metastasis-free survival, supported by advances in delivery techniques and a reassessment of safety concerns following the BART trial. Simultaneously, perioperative immunotherapy is reshaping the therapeutic landscape of muscle-invasive bladder cancer, with recent studies, such as CheckMate 274 and NIAGARA, establishing a new standard of care. The novelty of this review lies in the integration of the evolving role of ART within the immunotherapy era, with critical examination of its complementary value, toxicity profile and patient selection in light of modern systemic strategies. This narrative review provides an updated synthesis of current evidence and ongoing trials and offers a perspective on how ART can be optimally incorporated into multimodal management of high-risk bladder cancer.
Archivos espanoles de urologia. 2026 Mar [Epub]
Patricia Valencia Nieto, Fernando López-Campos, Patricia Diezhandino García, Víctor Duque-Santana, María Antonia Gómez-Aparicio, Abrahams Ocanto, María González de Dueñas, Xavier Maldonado Pijoan, Mohamed Shelan, Mario Álvarez-Maestro, Felipe Couñago
Radiation Oncology Department, Valladolid University Clinical Hospital, 47003 Valladolid, Spain., Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain., Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, 28223 Madrid, Spain., Department of Radiation Oncology, Hospital Universitario de Toledo, 45007 Toledo, Spain., Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain., Radiation Oncology Department, Hospital Universitario Vithas La Milagrosa, 28010 Madrid, Spain., Radiation Oncology Department, Vall d'Hebron University Hospital, 08035 Barcelona, Spain., Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland., Department of Urology, Hospital Universitario La Paz, 28046 Madrid, Spain.