Novel Imaging Techniques Prior to Surgical Management of Invasive Bladder Cancer: A Systematic Review

Purpose of Review To assess the diagnostic accuracy of novel imaging modalities in working up invasive bladder cancer prior to surgical management and their potential role in guiding treatment decisions. Recent Findings Multiple new imaging modalities, including VI-RADS and Biparametric MRI have been developed to better guide management of invasive bladder cancer. There lacks a comprehensive review of these modalities and their diagnostic performance. Summary We performed a systematic review following PRISMA guidelines. PubMed, Embase, and Scopus were searched through 2025. Studies reporting sensitivity and specificity of novel imaging for muscle invasion detection or nodal staging were included. Quality assessment used the QUADAS 2 tool. Thirty three studies encompassing 4,689 patients were included. Twenty three studies evaluated the Vesical Imaging Reporting and Data System for muscle invasion detection, achieving median sensitivity of 94% and specificity of 82% at a threshold of three or greater and 84% and 92%, respectively, at four or greater. Nine studies assessed positron emission tomography for nodal staging, with fluorodeoxyglucose positron emission tomography/computed tomography demonstrating superior sensitivity (23 to 81%) compared to conventional computed tomography (13 to 47%). Fibroblast activation protein inhibitor tracers showed the highest sensitivity (82 to 100%) with specificity of 82 to 90%. One radiomics study achieved 73% sensitivity and 84% specificity for lymph node detection. Novel imaging modalities demonstrate promising diagnostic accuracy for bladder cancer staging. The Vesical Imaging Reporting and Data System provides reliable muscle invasion assessment with threshold dependent performance. Positron emission tomography with fibroblast activation protein inhibitor tracers substantially improves nodal staging over conventional computed tomography. Integration of these modalities may optimize patient management, including use or omission of neoadjuvant therapy and consideration for organ sparing approaches. Prospective multicenter validation is needed.