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 in n = 141 (51%) cases. Of these, n = 125 (45.5%) were upstaged locally (>pT2) and n = 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.

Transurethral resection of the bladder tumor (TURBT) followed by intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is a standard treatment for high-risk non muscle-invasive bladder cancer (NMIBC). However, due to potential risk of dissemination, current guidelines recommend caution when proposing BCG treatment in immunocompromised patients. Our aim was to assess the efficacy and safety of BCG treatment in immunocompromised patients. Patients aged ≥18 with a diagnosis of bladder cancer (BC) who underwent BCG therapy in 2007-2021, were identified in the Merative^TM Marketscan® Research Commercial and Medicare databases. Multivariable Cox proportion hazard regressions adjusted by relevant confounders were performed to investigate the influence of immunosuppression on the events associated with progression and recurrence of BC, both in the unmatched cohort and after 1:2 propensity score matching (PSM). Also, subgroup analysis on progression in patients without cancer other than BC was conducted. Immunocompromised and immunocompetent patients had similar rates of disseminated BCG infection after intravesical immunotherapy. However, immunocompromised patients had shorter progression-free survival and higher probability of progression (aHR: 1.23, 95% CI: 1.11-1.38), as well as shorter recurrence-free survival and a higher probability of recurrence (aHR: 1.13, 95% CI: 1.05-1.20). Similar significant associations were observed in the PSM cohort. A subgroup analysis of patients without any additional oncological diagnoses beyond BC confirmed a higher likelihood of progression in the immunocompromised group (aHR: 1.34, 95% CI: 1.15-1.56). BCG immunotherapy is safe in immunocompromised patients. Nevertheless, the efficacy of intravesical BCG in these patients might be suboptimal thus advocating the need for appropriate counselling and a possible lower threshold to consider radical treatment.

Background and Objectives: Pathological upstaging from non-muscle-invasive bladder cancer (NMIBC) to muscle-invasive disease (MIBC) at radical cystectomy (RC) compromises preoperative risk stratification and may deprive patients of the survival benefit conferred by neoadjuvant chemotherapy. This study aimed to define the frequency and independent predictors of pathological upstaging in a contemporary single-institution cohort, and to characterise its impact on recurrence-free, disease-specific, and overall survival. Materials and Methods: We conducted a retrospective review of a prospectively maintained database of all patients who underwent RC and pelvic lymphadenectomy for urothelial bladder cancer at our institution between January 2009 and December 2023. Upstaging was defined as the final pathological stage ≥ pT2 or pN+ from a clinical stage of <T2N0M0. Clinicopathological factors were evaluated for their association with upstaging using chi-squared, Fisher’s exact, and logistic regression analyses. Survival outcomes—recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS)—were estimated by the Kaplan–Meier method and compared using the log-rank test. Multivariable Cox proportional hazards regression identified independent prognostic factors. Results: Of 1002 patients who underwent RC during the study period, complete clinicopathological data were available for 826. Primary clinical stage at presentation was MIBC (≥T2) in 448 (54.2%) and NMIBC (<T2) in 378 (45.8%). Among NMIBC patients, 102 (27.0%) were upstaged to MIBC at final pathology. Multivariable logistic regression identified concomitant carcinoma in situ (CIS) (p = 0.042), variant histology—predominantly squamous differentiation (p = 0.003)—and urethral involvement (p = 0.003) as independent predictors of upstaging. Upstaged patients had significantly worse 5-year RFS (p < 0.001), DSS (p = 0.01), and OS (p < 0.001) compared with patients who remained NMIBC. No statistically significant difference in survival was observed between patients upstaged at RC and those presenting with primary MIBC. Conclusions: Pathological upstaging occurs in more than a quarter of patients undergoing RC for NMIBC and confers a survival penalty equivalent to that of primary MIBC. Concomitant CIS, variant histology, and urethral involvement identify those at highest risk. These patients warrant aggressive preoperative counselling, expedited surgical planning, and consideration of perioperative systemic therapy.

(1) To examine 10-yr outcomes of Robot-assisted Radical Cystectomy (RARC) with Intracorporeal Ileal Conduit (ICIC) performed by international clinical fellows within a 1-yr RCS-Eng Urothelial Senior Fellowship Programme. (2) To explore fellows’ learning curve (LC) trajectories and perceived European Association of Urology Robotic Urology Section (ERUS) RARC/ICIC curriculum competency achievement. RARC/ICIC with curative intent for bladder cancer performed by supervised fellows (2015–2025) were reviewed. Perioperative outcomes and Kaplan-Meier survival trajectories served as surrogates of training competency and safety. Cumulative sum (CUSUM) model by operative time (OT) was applied for RARC/ICIC LC. Time to perceived proficiency across the 12 ERUS RARC/ICIC clinical modules was explored. A total of 423 procedures (median follow-up 39 mo, interquartile range 16–70) were included. Proficiency by CUSUM was identified at 30^th case, with significant reduction in total OT thereafter (350 vs 300 min, p = 0.017). Outcomes within learning and proficiency phases were comparable, including postoperative complications (36.6% vs 46.0%, p = 0.07), readmissions (16.9% vs 18.7%, p = 0.68), and cancer-specific survival (p = 0.97). ERUS curriculum acquisition was progressive: early modules in 0–1 mo by 88.9% of fellows and advanced modules in 4–6 mo by 100%. Skin-to-skin RARC/ICIC was achieved within ≤3, 4–6, and >6 mo in 11.1%, 33.3% and 55.6% of fellows, respectively. Previous robotic exposure was the only predictor for shorter time to independence (odds ratio, 2.34; 95% confidence interval 1.17–13.29). Post-fellowship, 88.9% of fellows continued independent RARC/ICIC practice. Structured Senior Robotic Fellowship training achieves safe and efficient acquisition of RARC/ICIC skills. The observed LC corroborates the educational value of the ERUS modular curriculum in the setting of a tertiary referral center.

The choice of ureteral access sheath (UAS) size in flexible ureteroscopy (fURS) is pivotal in balancing endoscopic performance with ureteral safety. Larger sheaths (12/14 Fr) provide superior irrigation flow and intrarenal pressure control but raise concerns regarding ureteral trauma, particularly in unstented ureters. This PRISMA-aligned systematic review (January 2010-August 2025) synthesizes the available evidence comparing 10/12 Fr and 12/14 Fr UAS, both standard and suction-enabled, in terms of pressure modulation, irrigation efficiency, thermal regulation, ureteral injury, stricture formation, and infectious outcomes. Emerging data show that suction-assisted 12/14 Fr sheaths significantly lower rates of postoperative fever and sepsis without increasing ureteral injury when applied judiciously. Pre-stenting remains a key strategy for minimizing insertion-related trauma. The findings highlight an evolving clinical paradigm in UAS selection: shifting from a purely size-based choice to a physiology-driven approach that optimizes safety, visibility, and procedural efficiency.