Contemporary Trends and Predictors of pT0 in Radical Cystectomy Specimens Among Non-Muscle and Muscle-Invasive...

Introduction: Absence of residual cancer in radical cystectomy (RC) specimens is a well-known positive prognostic factor for non-muscle and muscle-invasive bladder cancer (NMIBC and MIBC) in patients with or without neoadjuvant chemotherapy (NAC). Understanding the clinical and pathological features associated with a final pT0 status can provide valuable prognostic insights, serve as a surrogate marker for survival outcomes, and help identify candidates suitable for bladder-sparing strategies. Methods: Temporal trends and clinical/demographic characteristics across clinically high-/very-high-risk NMIBC or MIBC RC patients from 2009 to 2024 were explored. Subsequently, RC pT0 patients were propensity score-matched (PSM, 1:1 ratio) with the >pT0 population based on age-adjusted CCI and preoperative clinical stage (cTis-T1 vs. cT2). Multivariable regression modelling was applied to explore predictors of pT0 status stratified according to clinical NMIBC or MIBC status. Results: A total of 655 RCs performed with curative intent were included (43% for MIBC, 57% for NMIBC). Of these, 117 were pT0 at final pathological assessment (68 NMIBC and 49 MIBC). Subsequently, 228 PSM patients (114 pT0 vs. 114 >pT0) were extracted from the original cohort and stratified according to preoperative clinical stage (MIBC vs. NMIBC). In multivariable analysis, male gender was associated with an increased likelihood of pT0 status in the NMIBC cohort (adjusted odds ratio [aOR] 2.89, 95% CI 1.13-7.90). Conversely, BCG failure and concomitant CIS independently reduced the chances of achieving pT0 status (aOR: 0.40, 95% CI 0.19-0.99; aOR: 0.16, 95% CI 0.03-0.97). For MIBC patients, as expected, NAC more than doubled the chances of achieving pT0 status (aOR: 2.20, 95% CI 1.01-6.82). On the other hand, the concomitant presence of CIS reduced the likelihood of pT0 achievement (aOR 0.22, 95% CI, 0.06-0.80). In both cohorts, the presence of variant histology (VH) demonstrated a negative association with pT0 achievement; however, the estimated effect did not reach statistical significance (p = 0.09 and p = 0.08). Conclusions: Our findings suggest potentially raising the threshold for RC consideration in high-risk or very-high-risk NMIBC patients with a favourable risk profile. MIBC patients without additional risk factors (CIS and VH) are more likely to achieve a tumour-free status, particularly when adequately receiving NAC.