Radical cystectomy following cisplatin-based neoadjuvant chemotherapy (NAC) is still the standard approach for managing muscle-invasive bladder cancer (MIBC); however, a substantial proportion of patients are not candidates for surgery or cisplatin-based chemotherapy. The role of NAC followed by chemoradiation (CRT) in a bladder-preserving approach is not well established. This study aimed to evaluate the feasibility, survival outcomes, and prognostic factors associated with NAC followed by definitive CRT. We retrospectively analyzed MIBC patients treated with NAC and subsequent CRT between 2010 and 2023. Overall survival (OS) and event-free survival (EFS) were analyzed using the Kaplan–Meier method and Cox proportional hazards models. Among 224 MIBC patients treated with NAC, 132 patients received bladder-preserving CRT after NAC. The median OS for the entire cohort was 58 months (95% CI: 37.63–78.37). Median OS was significantly longer in patients with clinical complete response (cCR) compared with those without (73 vs. 29 months, p = 0.007). Median EFS was also superior in the cCR group (50 vs. 23 months, p = 0.022). In multivariable Cox regression analysis, achievement of cCR was independently associated with superior OS (HR 0.52, 95% CI 0.30–0.92, p = 0.028) and EFS (HR 0.54, 95% CI 0.32–0.93, p = 0.036). Moreover, the presence of baseline hydronephrosis predicted significantly worse OS (HR 2.37, 95% CI 1.32–4.25, p = 0.006) but showed no association with EFS. The type of NAC regimen (cisplatin vs. carboplatin) had no independent effect on survival. NAC followed by CRT is a feasible bladder-preserving approach for selected patients with MIBC, including those ineligible for cystectomy or cisplatin. Achievement of cCR is the most robust prognostic factor for both OS and EFS, supporting its role as a surrogate endpoint in this setting. These findings provide novel evidence for integrating NAC into bladder-preserving strategies and highlight clinical factors that may guide individualized treatment selection. A prospective randomized trial is warranted.
Mofid et al. (2026) studied this question.