The Contemporary Pattern of Radical Cystectomy in the Treatment of High-Grade Non-Muscle Invasive Bladder Cancer

Radical cystectomy (RC) remains the most effective treatment for high-grade non-muscle invasive bladder cancer (HG NMIBC) with high-risk features or after failed bladder preservation. Yet, utilization varies and understanding contemporary treatment patterns can help guide personalized care, especially amid expanding bladder-sparing options. This study assessed national trends and outcomes in HG NMIBC management with RC from 2010 to 2022.

The National Cancer Database (NCDB) was queried for clinically localized HG NMIBC. Determinants of RC use, time to RC, pathologic upstaging, and all-cause mortality were analyzed using multivariable linear, logistic, or Cox proportional hazards models. As a covariate, RC timing used 90- and 180-day cutoffs.

Across 220,672 HG NMIBC patients, RC use has declined since 2010. Black race had lower odds of RC use (odds ratios [OR] 0.89, P < .01), whereas variant histology (OR 4.88, P < .01) and treatment at academic centers (OR 3.47, P < .01) predicted higher odds. Among 9360 patients who underwent RC, time to surgery has increased. A total of 42% of RC patients had advanced upstaging, which was associated with RC performed 180 days after diagnosis (OR 1.2, P = .018), female sex (OR 1.14, P = .012), Black race (OR 1.2, P = .047), and variant histology (OR 1.94, P < .01). Treatment at academic centers (OR 0.73, P < .01) had lower upstaging risk. Improved all-cause mortality was linked to academic centers (hazard ratios 0.87, P < .01), with no significant difference by RC timing beyond 90 or 180 days (P > .05).

RC use for HG NMIBC has declined, while time to RC has increased. Longer time to RC was not uniformly associated with greater upstaging or all-cause mortality among RC patients. These findings highlight evolving practice patterns and need for long-term studies to optimize timing and integration of RC among emerging therapies. Limitations include lack of NCDB granularity to compare intentionally early versus deferred RC.