Introduction: Radical cystectomy (RC) is the gold standard for urothelial cT2-4a, N0, M0 muscle-invasive bladder cancer (MIBC). However, bladder-sparing strategies (BSS) such as Trimodality Therapy (TMT) have emerged as alternative treatments for a select group of localized muscle-confined (cT2) urothelial bladder cancers. Accordingly, reliable preoperative staging and a reliable risk factor assessment linked to pathological upstaging play a key role in adequate counselling and patient selection for BSS.Patients and Methods: cT2 MIBC patients undergoing RC at our institution from 2014 to 2024 were reviewed. Preoperative staging modalities, demographics, and tumour and patient characteristics were assessed. Multivariable logistic regression was applied to explore the relative effect of confounders on any pathological upstaging from robot-assisted or open RC specimens. Subgroup analysis according to the local upstaging (>pT2) or nodal dissemination (pN+) was also performed.Results:N= 275 RCs were included (73.5% males, 26.5% females). Upstaging was documented inn= 141 (51%) cases. Of these,n= 125 (45.5%) were upstaged locally (>pT2) andn= 35 (23%) yielded pN+ disease. Preoperative parameters like gender, the number of TURBTs, previous BCG exposure, and concomitant CIS did not significantly influence the risk of any kind of upstaging (p> 0.05). At multivariable analysis, neoadjuvant chemotherapy (NAC) and multi-disciplinary team (MDT) discussion were found protective (odds ratio [OR]: 0.4, 95%CI 0.2–0.7,p= 0.001 and OR: 0.51, 95%CI 0.2–0.9,p= 0.01). Preoperative FDG-PET assessment yielded higher risk for later pN upstaging (OR: 1.8, 95%CI 1–3,p= 0.05). HG/G3 features at TURBT along with mixed/pure histology variants in RC specimens were the most relevant independent predictors for both any and pT upstaging (OR: 4.3, 95%CI 1–34,p= 0.04 and OR: 2.3, 95%CI 1.1–4.6,p= 0.02 for any upstaging and OR: 5.6, 95%CI 1.3–36,p= 0.02 and OR: 2.5, 95%CI 1.3–5,p= 0.01 for pT upstaging, respectively).Conclusions: In this study, over half of the patients undergoing RC for cT2 were upstaged at the final pathology. Therefore, adequate counselling and examining the non-conventional criteria for prognosis is mandatory in the contemporary era of bladder-preservation strategies.
引言：根治性膀胱切除术（RC）是治疗尿路上皮cT2-4a、N0、M0肌层浸润性膀胱癌（MIBC）的金标准。然而，对于部分局限性肌层浸润（cT2）的尿路上皮膀胱癌患者，以三联疗法（TMT）为代表的保膀胱策略（BSS）已成为替代治疗方案。因此，可靠的术前分期及与病理分期升级相关的风险评估，对于BSS的充分医患沟通和患者选择至关重要。 患者与方法：回顾性分析2014年至2024年在本机构接受RC治疗的cT2 MIBC患者。评估术前分期方式、人口统计学特征、肿瘤及患者临床特点。采用多变量逻辑回归分析混杂因素对机器人辅助或开放RC标本病理分期升级的相对影响，并根据局部升级（>pT2）或淋巴结转移（pN+）进行亚组分析。 结果：共纳入275例RC患者（男性73.5%，女性26.5%）。141例（51%）出现病理分期升级，其中125例（45.5%）为局部升级（>pT2），35例（23%）出现pN+病变。性别、经尿道膀胱肿瘤切除术次数、既往卡介苗暴露史、伴发原位癌等术前参数对各类分期升级风险均无显著影响（p>0.05）。多变量分析显示，新辅助化疗（NAC）和多学科团队（MDT）讨论具有保护作用（比值比[OR]：0.4，95%CI 0.2–0.7，p=0.001；OR：0.51，95%CI 0.2–0.9，p=0.01）。术前FDG-PET评估与后续pN分期升级风险升高相关（OR：1.8，95%CI 1–3，p=0.05）。TURBT标本中的高级别/G3特征及RC标本中的混合型/纯组织学变异是各类分期升级及pT升级最相关的独立预测因素（各类升级：OR：4.3，95%CI 1–34，p=0.04；OR：2.3，95%CI 1.1–4.6，p=0.02；pT升级：OR：5.6，95%CI 1.3–36，p=0.02；OR：2.5，95%CI 1.3–5，p=0.01）。 结论：本研究中超过半数cT2期接受RC治疗的患者在最终病理检查中出现分期升级。因此，在当代保膀胱治疗策略背景下，必须进行充分的医患沟通并审视非常规预后评估标准。
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