BACKGROUND: Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial. OBJECTIVE: To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management. DESIGN: A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference. SETTING: Online Delphi survey and consensus conference. PARTICIPANTS: The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus). RESULTS AND LIMITATIONS: Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease. CONCLUSIONS: These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

2nd Propaedeutic Dept of Internal Medicine Medical School National and Kapodistrian University of Athens Athens Greece

Academic Urology Unit University of Aberdeen Aberdeen UK

Academic Urology Unit University of Aberdeen Aberdeen UK; Department of Urology Aberdeen Royal Infirmary Aberdeen UK

Cancer Sciences Unit University of Southampton Southampton UK

Cancer Treatment Centre Sorlandet Hospital Kristiansand Norway

Clinica HematoOncologica Bonadona Prevenir Universidad Metropolitana Clinica Club de Leones Barranquilla Colombia

CRUK MRC Oxford Institute for Radiation Oncology University of Oxford Oxford UK

Département de Médecine Oncologique Gustave Roussy INSERM U981 Université Paris Sud Université Paris Saclay Villejuif France

Department Innere Medizin Abteilung Onkologie und Hämatologie Kantonsspital Graubünden Chur Switzerland

Department of Biomedical Sciences Humanitas University Milan; Humanitas Research Hospital Milan Italy

Department of Biomedical Sciences Humanitas University Milan; Humanitas Research Hospital Milan Italy; Department of Radiology and Nuclear Medicine Radboud University Medical Center Nijmegen The Netherlands; Department of Radiology and Nuclear Medicine Rijnstate Hospital Arnhem The Netherlands

Department of Cancer Medicine Hôpital Saint Louis Paris

Department of Clinical Oncology Leiden University Medical Center Leiden

Department of Imaging and Nuclear Medicine Royal Sussex County Hospital Brighton; Brighton and Sussex Medical School Brighton UK

Department of Medical Oncology and Hematology University Hospital Zürich Zürich Switzerland

Department of Medical Oncology Centre Georges François Leclerc Dijon France

Department of Medical Oncology Istituto Nazionale Tumori of Milan Milan Italy

Department of Medicine Memorial Sloan Kettering Cancer Center New York; Weill Cornell Medical College New York USA

Department of Nuclear Medicine Policlinico S Orsola University of Bologna Bologna Italy

Department of Nuclear Medicine Universitätsklinikum Essen Essen Germany

Department of Oncology Akershus University Hospital Lørenskog; Faculty of Medicine University of Oslo Oslo Norway

Department of Oncology and Hemato oncology Università degli Studi di Milano Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy

Department of Oncology and Hemato oncology University of Milan Milan; Division of Radiotherapy IEO European Institute of Oncology IRCCS Milan Italy

Department of Oncology Hospital Universitario San Roque Canarias; Universidad Fernando Pessoa Canarias Spain

Department of Oncology Rigshospitalet University Hospital of Copenhagen Copenhagen Denmark

Department of Pathology Erasmus Medical Center Rotterdam The Netherlands

Department of Pathology Tenon Hospital HUEP Paris; Sorbonne University Paris France

Department of Radiation Oncology Amsterdam University Medical Centers University of Amsterdam Amsterdam

Department of Radiation Oncology Eberhard Karls University Tübingen Germany

Department of Radiation Oncology Europe Hospitals Brussels Brussels Belgium

Department of Radiation Oncology Gustave Roussy Institute Villejuif France

Department of Radiation Oncology Radboud University Medical Center Nijmegen The Netherlands

Department of Radiation Oncology University Hospital Ulm Ulm Germany

Department of Radiology and Nuclear Medicine Division of Genitourinary Radiology and Mammography Ghent University Hospital Ghent

Department of Radiology and Nuclear Medicine Radboud University Medical Center Nijmegen The Netherlands

Department of Radiology Copenhagen University Hospital Herlev and Gentofte Herlev Denmark

Department of Radiotherapy Institut Bergonié Bordeaux France

Department of Radiotherapy Oncology Ghent University Hospital Ghent Belgium

Department of Surgery Austin Health University of Melbourne Melbourne; Eastern Health Clinical School Monash University Melbourne Australia

Department of Surgery Faculty of Medicine Nursing and Health Sciences Monash University Clayton Australia

Department of Surgical and Perioperative Sciences Urology and Andrology Umeå University Umeå Sweden

Department of Urologic Sciences Vancouver Prostate Centre University of British Columbia Vancouver Canada

Department of Urology Aberdeen Royal Infirmary Aberdeen UK

Department of Urology Amsterdam University Medical Centers University of Amsterdam Amsterdam The Netherlands

Department of Urology and Paediatric Urology University Hospital of Würzburg Julius Maximillians University Würzburg Germany

Department of Urology Auckland City Hospital Auckland New Zealand

Department of Urology Bichat Claude Bernard Hospital Assistance Publique Hôpitaux de Paris Paris; Paris Descartes University Paris France

Department of Urology Caritas St Josef Medical Center University of Regensburg Regensburg Germany

Department of Urology Centro Hospitalar São João Porto; Life and Health Sciences Research Institute School of Medicine University of Minho Braga Portugal

Department of Urology Division of Surgery The University of Texas MD Anderson Cancer Center Houston USA

Department of Urology Eberhard Karls University Tübingen Tübingen Germany

Department of Urology Erasmus University Medical Center Rotterdam The Netherlands

Department of Urology Fundació Puigvert Universitat Autònoma de Barcelona Barcelona Spain

Department of Urology Ghent University Hospital Ghent Belgium

Department of Urology Hospital Foch University of Versailles Saint Quentin en Yvelines Suresnes France

Department of Urology Hospital Universitario Fundación de Alcorcón Madrid Spain

Department of Urology Inselspital Bern University Hospital Berne Switzerland

Department of Urology Luzerner Kantonsspital Luzern Switzerland

Department of Urology Medical University of Vienna Vienna Austria

Department of Urology Medical University of Vienna Vienna Austria; Department of Cell and Molecular Biology George Emil Palade University of Medicine Pharmacy Science and Technology of Targu Mures Targu Mures Romania

Department of Urology Medical University of Vienna Vienna Austria; Department of Urology Charité University Hospital Berlin Germany

Department of Urology Medizinische Universität Graz Graz Austria

Department of Urology Pediatric Urology and Urologic Oncology Kliniken Essen Mitte Essen Germany

Department of Urology Radboud University Medical Center Nijmegen

Department of Urology Rechts der Isar Medical Center Technical University of Munich Munich Germany

Department of Urology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark

Department of Urology Royal Surrey County Hospital Guildford UK

Department of Urology Ruhr University Bochum Marien Hospital Herne Germany

Department of Urology Saint John Emergency Clinical Hospital Bucharest Romania

Department of Urology Sorbonne Université GRC n°5 ONCOTYPE URO AP HP Hôpital Pitié Salpêtrière Paris

Department of Urology Tampere University Hospital Tampere Finland

Department of Urology University Hospital La Paz Madrid Spain

Department of Urology University Hospital of Turku Turku Finland

Department of Urology University Hospitals Leuven Leuven Belgium

Department of Urology University Medical Center Groningen University of Groningen Groningen The Netherlands

Department of Urology University Medical Center Hamburg Eppendorf Hamburg

Department of Urology University Medical Center Utrecht Utrecht The Netherlands

Department of Urology University of California San Diego Pathology La Jolla USA

Department of Urology Urological Research Institute Milan; Vita Salute University San Raffaele Scientific Institute Milan Italy

Department of Urology UWA Medical School University of Western Australia Perth Australia

Department of Urology Weill Cornell Medical College New York; Urology Service Department of Urology Memorial Sloan Kettering Cancer Center New York USA

Department of Urology Westmead Hospital University of Sydney Sydney Australia

Depatment of Urology 2nd Faculty of Medicine Hospital Motol Charles University Prague Czech Republic; Department of Urology Medical University of Vienna Vienna Austria

Depatment of Urology 2nd Faculty of Medicine Hospital Motol Charles University Prague Czech Republic; Department of Urology Medical University of Vienna Vienna Austria; Department of Urology Weill Cornell Medical College New York; Department of Urology University of Texas Southwestern Medical Center Dallas USA; Institute for Urology and Reproductive Health 1 M Sechenov 1st Moscow State Medical University Moscow Russia

Division of Cancer Sciences University of Manchester Manchester; Rosemere Cancer Centre Lancashire Teaching Hospitals Preston UK

Division of Cancer Sciences University of Manchester Manchester; The Christie NHS Foundation Trust Manchester UK

Division of Cancer Sciences University of Manchester Manchester; The Christie NHS Foundation Trust Manchester UK; Division of Oncology and Haematology Kantonsspital St Gallen St Gallen; University of Bern Bern Switzerland

Division of Cancer Sciences University of Manchester Manchester; The Christie NHS Foundation Trust Manchester UK; Mount Vernon Centre for Cancer Treatment London UK

Division of Radiotherapy and Imaging The Institute of Cancer Research London; Department of Clinical Oncology The Royal Marsden NHS Foundation Trust London UK

Division of Radiotherapy and Imaging The Institute of Cancer Research London; Department of Clinical Oncology The Royal Marsden NHS Foundation Trust London UK; Department of Medicine University of Melbourne Melbourne; Monash University Melbourne Australia

Division of Urology IREC Cliniques Universitaires Saint Luc UCL Brussels Belgium

Division of Urology Molinette Hospital University of Studies of Torino Torino Italy

EAU Guidelines Office Arnhem The Netherlands

Emeritus Professor of Radiation Oncology Grenoble Alpes University Grenoble France

Emeritus Professor The Institute of Cancer Research London UK; Emeritus Professor The Institute of Cancer Research London UK

Hospices Civils de Lyon Service d'Imagerie Urinaire et Vasculaire Hôpital Edouard Herriot Lyon; Université de Lyon Université Lyon 1 Faculté de Médecine Lyon Est Lyon France

Huntsman Cancer Institute University of Utah Salt Lake City USA

Icahn School of Medicine Mount Sinai Health System New York City USA; Department of Urology Karolinska Institutet Stockholm Sweden

IMIM Hospital del Mar Medical Research Institute Barcelona Spain; Harvard Medical School Boston USA

Institute of Cancer Sciences College of Medicine Veterinary and Life Sciences University of Glasgow Glasgow UK

Institute of Pathology Friedrich Alexander University Erlangen Nürnberg Erlangen Germany

Leeds Institute of Medical Research University of Leeds Leeds UK

Medical Oncology Department 12 de Octubre University Hospital Madrid Spain

Molecular Imaging Program National Cancer Institute Bethesda USA

Radiation Oncology Department Centre Hospitalier Régional Universitaire Jean Minjoz of Besançon INSERM UMR 1098 Besançon France; Radiation Oncology Department Centre Hospitalier Universitaire Vaudois Université de Lausanne Lausanne Switzerland

Servicio de Urología Fundación Instituto Valenciano de Oncología Valencia Spain

The Royal Free NHS Trust London; Barts Cancer Institute Queen Mary University of London London UK

UMC Utrecht Cancer Center MS Oncologic Urology Utrecht The Netherlands

University Hospitals Birmingham NHS Foundation Trust Birmingham; Institute of Cancer and Genomic Sciences University of Birmingham Birmingham

Uro Oncology Unit Hospital Clinic University of Barcelona Barcelona Spain

Urology Department Canisius Wilhelmina Ziekenhuis Nijmegen Nijmegen The Netherlands

Urology Service Department of Urology Memorial Sloan Kettering Cancer Center New York USA

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