This review documents the evidence that combination chemotherapy, known to be useful in metastatic disease, offers an advantage in the context of apparently localized disease. The use of neoadjuvant chemotherapy before cystectomy shows that pathologic complete responses can be obtained one-third of the time and that this, in combination with an aggressive TURBT, can be one strategy to preserve the bladder. The response to chemotherapy strongly predicts ultimate survival whatever the local therapy. Two recently updated randomized trials raise the possibility that neoadjuvant chemotherapy has a small but detectable survival benefit yet its use is controversial in everyday practice because of the desire of surgeons to perform an immediate cystectomy. The role of adjuvant chemotherapy remains undefined.
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