Optimizing oncological outcomes in high-grade non-muscle invasive bladder cancer: The impact of a surgeon-led treatment pathway.

INTRODUCTION

The management of high-grade non-muscle invasive bladder cancer (HG-NMIBC) is complex, requiring accurate transurethral resection of bladder tumors (TURBT), intravesical therapy, and diligent follow-up. We hypothesized that centralizing patient care from the first diagnosis could improve oncological outcomes in these patients.

METHODS

We conducted a retrospective analysis of 175 consecutive patients with HG-NMIBC who underwent TURBT performed by a highly experienced surgeon at a tertiary referral center (2012-2023). All specimens were reviewed by 2 experienced uropathologists, and all patients received Bacillus Calmette-Guérin (BCG). Group A included patients treated solely by the experienced surgeon, while Group B consisted of patients initially treated elsewhere before undergoing TURBT at our center. Propensity score-based overlap weighting was applied to balance the groups. Kaplan-Meier curves and weighted univariable Cox regression models were used to estimate disease-free survival (DFS, defined as recurrence or progression), progression-free survival (PFS), and cancer-specific survival (CSS).

RESULTS

Group A included 94 (54%) patients, while Group B 81 (46%) patients. Median age was 71 years. T1HG disease was present in 126 (72%) patients and was equally distributed (P = 0.7). Early epirubicin instillation (EI) was given to 52% in Group A and 37% in Group B (P = 0.045). pT0 rate at re-TURBT was 59% in Group A vs. 36% in Group B (P = 0.025), with HG disease in 31% and 52% (P = 0.027), respectively. The 5-year DFS was 75% in Group A and 51% in Group B (HR:0.36, P < 0.001). Group A had better PFS (HR:0.31, P = 0.011) and CSS (HR:0.36, P = 0.023). After weighting, DFS (HR:0.47, P = 0.014), PFS (HR:0.38, P = 0.034), and CSS (HR:0.25, P = 0.002) remained significant. Overall, 21 (12%) patients underwent radical cystectomy.

CONCLUSIONS

In this single-center cohort of HG-NMIBC managed within a structured, surgeon-led pathway at a tertiary referral center, long-term disease control rates were highly favorable. Surgeon experience from first diagnosis, adherence to surgical protocols, intravesical therapy, and follow-up are crucial for improving oncological outcomes in HG-NMIBC patients.