Clinically lymph node-positive urothelial bladder cancer treated with upfront radical cystectomy: Diagnostic accuracy of MRI and long-term oncologic outcomes.

Objective: This study aimed to evaluate the diagnostic accuracy of MRI in the detection of nodal metastasis in urothelial bladder cancer (UBC) and to assess the long-term oncological outcomes of upfront radical cystectomy (RC) in patients with clinical lymph node-positive (cN+) muscle-invasive UBC. Methods: A retrospective analysis of 1053 consecutive UBC patients treated with RC between January 1, 2004 and January 31, 2014 was performed. Radiological, clinical, pathological data and survival outcomes of cN+ patients were collected. Cox regression analyses were used to assess the impact of the radiological, clinical, and pathological variables on survival. Results: A total of 233 (22%) patients were diagnosed with cN+ UBC with a mean age of 57.3 (standard deviation 8.1) years, of whom 144 (62%) were found to have pathologically positive lymph nodes at final pathology. Adjuvant chemotherapy was administered to 58 (25%) patients. The sensitivity, specificity, positive predictive value, and negative predictive value of MRI to detect pathological lymph node-positive disease were 51%, 88%, 62%, and 83%, respectively. The overall accuracy was 79% with a calculated area under the curve of 70%. The median follow-up period was 17.0 (interquartile range 8.2-58.7) months. During this period, 54 (23%) patients developed local recurrence while 56 (24%) experienced distant metastasis and the estimated 1-, 3-, 5-, and 10-year recurrence-free survival for cN+ patients were 78%, 56%, 51%, and 48%, respectively. On multivariate analysis, advanced pT stage (pT3-4 vs. pT2) was the only independent predictor of recurrence-free survival. Conclusion: Despite its potential in preoperative assessment of muscle-invasive UBC, MRI showed limited sensitivity for detecting node-positive disease. Notably, in patients with MRI-detected cN+ UBC, those who underwent upfront RC demonstrated long-term survival outcomes comparable to those treated with neoadjuvant chemotherapy followed by consolidative cystectomy in previously published studies.