Introduction: Staging inaccuracies in muscle-invasive bladder cancer (MIBC) can lead to undertreatment or overtreatment. We evaluated clinical and pathological predictors of pathologic upstaging (pUS) stratifying by neoadjuvant chemotherapy (NAC) receipt among patients undergoing robot-assisted radical cystectomy (RARC). Methods: We included patients with MIBC (≥cT2N0M0) who underwent RARC from February 2004 through October 2020. Patients were grouped as (1) pUS with NAC, (2) pUS without NAC, and (3) no pUS (reference). Baseline characteristics were summarized using descriptive statistics. Logistic regression assessed the association between baseline characteristics and odds for upstaging. Kaplan–Meier method estimated overall survival (OS) and recurrence-free survival (RFS), and log-rank test compared the survival distribution between groups. Univariable and multivariable Cox regression models identified variables associated with OS and RFS. Results: Among 277 patients, 38.6% (n = 107) were upstaged with NAC (n = 37) or without NAC (n = 70). Most were male (79%), white (72%), and had cT2 stage (85%). Median age at surgery was 72 yrs. Preoperative hydronephrosis showed higher odds of upstaging [OR 2.24 (95% CI, 1.31–3.81),p= 0.003]. pUS with NAC [HR 1.99 (95% CI, 1.23–3.22),p= 0.005] and without NAC [HR 3.18 (95% CI, 2.21–4.55),p< 0.001] predicted worse OS (33.5 vs. 18.8 mos) compared to patients without pUS (135.3 mos). pUS with NAC [HR 2.49 (95% CI, 1.58–3.94)p< 0.001] and without NAC [HR 3.02 (95% CI 2.11–4.31),p< 0.001] predicted worse RFS. Conclusions: Preoperative hydronephrosis was the strongest predictor for pUS, independent of other baseline covariates. This highlights the need for better pre-operative risk stratification strategies for patients with MIBC undergoing RARC.
引言：肌层浸润性膀胱癌（MIBC）的分期不准确可能导致治疗不足或过度治疗。本研究在接受机器人辅助根治性膀胱切除术（RARC）的患者中，按是否接受新辅助化疗（NAC）分层，评估了病理分期升级（pUS）的临床和病理预测因素。方法：我们纳入了2004年2月至2020年10月期间接受RARC的MIBC（≥cT2N0M0）患者。患者被分为三组：（1）接受NAC后发生pUS，（2）未接受NAC发生pUS，以及（3）未发生pUS（参照组）。使用描述性统计总结基线特征。通过逻辑回归分析评估基线特征与分期升级几率之间的关联。采用Kaplan-Meier法估计总生存期（OS）和无复发生存期（RFS），并使用对数秩检验比较组间生存分布。通过单变量和多变量Cox回归模型识别与OS和RFS相关的变量。结果：在277例患者中，38.6%（n = 107）发生了分期升级，其中接受NAC者37例，未接受NAC者70例。大多数患者为男性（79%）、白人（72%），临床分期为cT2期（85%）。手术中位年龄为72岁。术前肾积水显示出更高的分期升级几率[OR 2.24（95% CI，1.31–3.81），p = 0.003]。与未发生pUS的患者（OS为135.3个月）相比，接受NAC后发生pUS[HR 1.99（95% CI，1.23–3.22），p = 0.005]和未接受NAC发生pUS[HR 3.18（95% CI，2.21–4.55），p < 0.001]均预示着更差的OS（分别为33.5个月和18.8个月）。接受NAC后发生pUS[HR 2.49（95% CI，1.58–3.94），p < 0.001]和未接受NAC发生pUS[HR 3.02（95% CI，2.11–4.31），p < 0.001]也预示着更差的RFS。结论：术前肾积水是pUS最强的预测因素，且独立于其他基线协变量。这凸显了对接受RARC的MIBC患者需要更好的术前风险分层策略。
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