777 Background: Bladder-preserving trimodal therapy, which combines maximal transurethral resection (TUR) and concurrent chemoradiation, is recognized as a promising alternative for treating muscle-invasive bladder cancer (MIBC). However, the impact of maximal TUR—defined as visually complete tumor resection—performed prior to neoadjuvant chemotherapy (NAC) on oncological outcomes in patients undergoing radical cystectomy (RC) remains unclear. Methods: This multicenter retrospective study included 550 patients with MIBC who received 2–4 cycles of NAC followed by RC. Patients were divided into two groups: those who underwent maximal TUR prior to NAC (maximal TUR group) and those who did not (control group). Rates of pathological downstaging, <ypT2, and ypT0 were compared between the two groups. Multivariable Cox proportional hazards regression analysis was used to evaluate the effect of maximal TUR on recurrence-free survival (RFS). Results: The median age and follow-up duration were 69 years and 54 months, respectively. The maximal TUR group showed significantly higher rates of downstaging (76% vs. 61%, P < 0.001), <ypT2 (73% vs. 39%, P < 0.001), and ypT0 (46% vs. 15%, P < 0.001) compared to the control group. RFS was significantly longer in the maximal TUR group ( P < 0.001). After adjusting for confounding variables, maximal TUR remained significantly associated with improved RFS ( P = 0.032; hazard ratio: 0.616; 95% confidence interval: 0.396–0.958). Subgroup analyses demonstrated that the survival benefit of maximal TUR was consistent across both <cT3 and cN0 ( P = 0.001) and ≥cT3 and/or ≥cN1 ( P = 0.014) subgroups. Cancer-specific survival and overall survival were also significantly longer in the maximal TUR group ( P < 0.001 and P = 0.004, respectively). Conclusions: Maximal TUR prior to NAC may contribute to improved oncological outcomes in patients undergoing RC for MIBC. Multivariable analysis for RFS. Factor P value HR 95% CI Performance status Continuous 0.064 1.482 0.977–2.250 Histological type Pure UC 0.828 1.048 0.684–1.606 Tumor grade Grade 3 0.346 0.802 0.507–1.268 Pathological T stage ≥ pT3 0.013 1.723 1.121–2.649 LVI Positive <0.001 2.945 1.875–4.625 Pathological N stage ≥ pN1 0.009 1.760 1.154–2.684 Surgical margin Positive 0.380 1.334 0.701–2.538 Urinary diversion Neobladder 0.006 0.615 0.434–0.871 Maximal TUR Performed 0.032 0.616 0.396–0.958
Fujita et al. (2026) studied this question.