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Purpose: To improve patient selection for neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) in bladder cancer patients (BCa). Methods: Retrospective evaluation of 1057 patients with cT2–4N0M0 BCa treated with RC and pelvic lymph node dissection between 1990 and 2018 at 3 referral centers. Adverse pathologic features (APF) were defined as pT3–pT4/pN + disease at RC. A regression tree model (CART) was used to assess preoperative risk group classes. A multivariable logistic regression (MVA) was performed to identify predictors of APF at RC. Results: Median age was 70 years and most of the patients were men (83%). Of the 1057 patients included in our study, 688 (65%) had APF. CART analysis was able to stratify patients into 3 risk groups: low (cT2 and single disease, odds ratio [OR] 0.62), intermediate (cT2 and multiple disease, OR 1.08), and high (cT3–cT4, OR 1.28). On MVA APF were associated with variant histology (odds ratio [OR] 3.97, 95% confidence interval [CI] 1.46–10.83, p = 0.007), multifocality at TUR (OR 2.56, CI 1.27–5.17, p = 0.09), completeness of resection (OR 0.47, CI 0.23–0.96, p = 0.04) and clinical extravesical disease (OR 3.42, CI 1.63–7.14, p = 0.001). Conclusion: We defined three pre-operative risk classes. Our results indicate that patients with a cT3–T4 disease are those who might benefit more from NAC whereas those with T2 single disease should be those to whom NAC probably shouldn't be proposed. Given the high rate of understaging in BCa patients, NAC can be proposed in selected cases of cT2/multifocal disease. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the role of a complete transurethral resection of bladder tumors (c-TURBT) on oncological outcomes after radical cystectomy (RC) and its relationship with adverse pathological features. Methods: We retrospectively analyzed data of 727 patients treated with RC and bilateral pelvic lymph node dissection at three tertiary referral centers. Possible c-TURBT was reported by the treating surgeon. Multivariable Cox regression analyses were used to assess the relationship of c-TURBT and survival outcomes after surgery in 1:1 propensity score-matched cohort adjusted for age and gender. Moreover, multivariable logistic regression (MVA) was built to predict the relationship between c-TURBT and pT3–T4 stages at RC, lymph node invasion (LNI) and positive soft tissue surgical margin (STSM). Results: A total of 433 (60%) patients received a c-TURBT. 3.0% of patients with a c-TURBT achieved a pT0–pTa–pTis status vs. 2.0% of patients with incomplete TURBT. At multivariable Cox regression analyses, c-TURBT was not associated with survival outcomes. At MVA, incompleteness of TURBT was significantly associated with a pT3–T4 stage [odds ratio (OR) 8.04, 95% confidence interval (CI) 2.33–27.67, p = 0.001]. No significant association was found between c-TURBT, LNI and STSM. Conclusion: We found a low rate of achievement of pT0 stage at RC. An incomplete TURBT before RC represented a predictor of pT3–T4 stages, but no effect of a c-TURBT was shown on survival outcomes. Given the current inadequacy of clinical staging strategies with more than 50% of extravesical disease being under-staged, our results could improve patients selection for NAC, driving the decision-making in doubtful cases. [ABSTRACT FROM AUTHOR]