Stromal innervation is prognostic in non-muscle-invasive bladder cancer and predicted by a distinct microenvironmental transcriptomic signature.

Peripheral nerves are increasingly recognized as active components of the tumor microenvironment (TME). Yet, their role in non-muscle-invasive bladder cancer (NMIBC) and response to Bacillus Calmette-Guérin (BCG) remains poorly defined. Using multispectral imaging, we characterized autonomic and sensory nerve populations within the tumor-adjacent stroma of 260 treatment-naive high-risk NMIBC tumor regions from 151 patients. Stromal tumor-associated nerve (STaN) abundance varied substantially across patients and was associated with aggressive clinicopathological features, BCG failure, and disease progression. Unsupervised clustering resolved distinct STaN phenotypic groups with differential clinical and spatial associations. Noradrenergic and neurochemically heterogeneous STaN populations showed the strongest associations with adverse outcomes. In contrast, a mixed population of nerves with high expression of the synaptic vesicle protein synaptophysin exhibited prominent spatial remodeling associated with BCG failure, despite limited prognostic value by abundance alone. Integration with an independent single-cell atlas nominated cancer-associated fibroblasts and mast cells as candidate cellular intermediaries of neural communication within the TME. Matched transcriptomic profiling revealed coordinated neuronal, extracellular matrix, lipid metabolism, and immune programs in STaN-high tumors, whereas STaN-low tumors were preferentially enriched for proliferative and hypoxic stress-response pathways. Leveraging these transcriptional features, we developed a transcriptomic classifier that distinguished STaN-high from STaN-low tumors in an independent test cohort (AUC = 0.87) and stratified clinical outcomes in additional patient cohorts. Together, these findings establish tumor innervation as a heterogeneous and clinically relevant feature of the NMIBC microenvironment, with neural abundance, phenotype, and spatial organization capturing distinct aspects of tumor behavior and clinical outcome.