Abstract
Background
Over the last two decades, significant advances in the perioperative management of muscle-invasive bladder cancer, such as enhanced recovery protocols, increased use of neoadjuvant chemotherapy, improved care pathways, and stronger multidisciplinary collaboration, have reshaped surgical outcomes. This study aimed to evaluate the evolution of care and oncological outcomes in patients undergoing radical cystectomy at a Brazilian tertiary cancer center over 20 years.
Methods
We retrospectively analyzed clinical, surgical, and pathological data from patients with bladder cancer who underwent radical cystectomy between January 2005 and April 2025. Patients were stratified into two cohorts according to the year of surgery (2005–2014 vs. 2015–2025). Survival analyses were performed using Kaplan–Meier curves to compare overall survival, cancer-specific survival, and recurrence-free survival between periods.
Results
A total of 733 patients were included (mean age, 66.2 years; 69.2% male). An age-adjusted Charlson Comorbidity Index ≥ 3 was present in 90.4%, and preoperative hydronephrosis in 41.5%. Locally advanced disease (pT3–pT4) occurred in 50.9%, lymph node positivity (pN+) in 26.6%, and 34.5% received neoadjuvant chemotherapy. Early complications (< 30 days) occurred in 51.2%, early reoperation in 19.3%, and late complications (30–90 days) in 24.0%, with 33.3% classified as Clavien–Dindo grade ≥ III. On multivariable Cox regression, treatment period remained independently associated with improved overall survival (HR 0.75, 95% CI 0.58–0.97; p = 0.029). Clinical stage was also independently associated with overall survival (overall p = 0.046), with advanced stage increasing the hazard of death (HR 1.48, 95% CI 1.08–2.02; p = 0.015). Kaplan–Meier analysis showed significantly improved overall, cancer-specific, and recurrence-free survival in 2015–2025 versus 2005–2014 (all log-rank p < 0.001).
Conclusion
Improved survival after radical cystectomy over the last decade reflects advances in perioperative care in the management of bladder cancer patients undergoing radical cystectomy.
Keywords: Bladder cancer, Radical Cystectomy, Epidemiology, Perioperative therapy
Background
Bladder cancer is the ninth most incident malignancy worldwide, accounting for approximately 3% of all cancer diagnoses, with an estimated 614,000 new cases and 220,000 deaths in 2022, ranking 13th among causes of cancer mortality globally [1]. The incidence is markedly higher in men than in women, with age-standardized rates of approximately 9.3 versus 2.4 per 100,000, reflecting differences in exposure to major risk factors [1, 2]. More than 90% of cases correspond to urothelial carcinoma, the predominant histological subtype originating from the urothelial lining of the bladder [3, 4].
The most relevant risk factor for bladder cancer is tobacco smoking, responsible for a substantial proportion of cases, followed by occupational exposure to aromatic amines and industrial chemicals, environmental carcinogens, and genetic susceptibility [2, 3]. The disease predominantly affects older adults, with incidence increasing significantly after the fifth decade of life, contributing to a higher burden of comorbidities at diagnosis and treatment [4].
For muscle-invasive bladder cancer (MIBC), the gold-standard curative treatment is radical cystectomy with pelvic lymphadenectomy, as recommended by international guidelines [3]. Robust evidence demonstrates that cisplatin-based neoadjuvant chemotherapy provides an absolute overall survival benefit of approximately 8% at 5 years, supporting its routine use in eligible patients [5]. However, radical cystectomy remains a complex and morbid procedure, with ongoing emerging techniques [6]. Large contemporary series report 30-day mortality rates of 2–3% and 90-day mortality of up to 7–8%, highlighting the substantial perioperative risk associated with this surgery [7, 8].
Accumulating evidence indicates that institutional surgical volume plays a crucial role in outcomes, with high-volume centers consistently demonstrating lower perioperative mortality, lower complication rates, and improved care efficiency [9, 10]. Despite the epidemiological relevance of bladder cancer and the increasing complexity of its management, there is a lack of large, contemporary Latin American series reporting long-term clinical and oncological outcomes after radical cystectomy. The objective of this study is to evaluate the evolution of perioperative care and oncological outcomes in patients undergoing radical cystectomy at a Brazilian tertiary cancer center by comparing mortality, recurrence, and survival over a 20-year period.
Methods
Study design and patients
This retrospective cohort study was approved by the institutional ethics committee. We reviewed medical records of consecutive patients with bladder cancer who underwent radical cystectomy with pelvic lymph node dissection at a tertiary oncological referral center between January 2005 and April 2025.
Surgical indications included muscle-invasive bladder cancer or non–muscle-invasive disease refractory to intravesical Bacillus Calmette–Guérin therapy. Patients presenting non-nodal distant metastases at diagnosis or missing information on lymph node yield were excluded from the analysis. All surgical specimens were evaluated by dedicated uropathologists, and histological classification followed the World Health Organization criteria, while tumor staging was performed according to the American Joint Committee on Cancer 2022 system.
The indication for neoadjuvant chemotherapy was based on physician judgment in accordance with international guidelines. Postoperative surveillance followed the European Association of Urology recommendations. Disease recurrence was assessed through cross-sectional imaging and/or histological confirmation. Patients who missed scheduled follow-up visits were actively contacted via telephone call whenever they missed a consultation, and causes of death were obtained from medical records whenever available.
Clinical, pathological, and perioperative data were systematically extracted from electronic health records. Patient-related variables included age at surgery, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, Karnofsky Performance Status (KPS), Eastern Cooperative Oncology Group (ECOG) performance status, smoking status, age-adjusted Charlson Comorbidity Index (ACCI), prior abdominal surgery, diabetes mellitus, use of anticoagulant or antiplatelet agents, and preoperative hydronephrosis. Tumor-related variables comprised clinical and pathological stage, histological subtype, and presence of lymph vascular invasion.
Treatment- and procedure-related variables included receipt of neoadjuvant chemotherapy, surgical approach, type of urinary diversion, length of hospital stay, operative time, estimated blood loss, number of lymph nodes removed, number of positive lymph nodes, and lymph node density. Perioperative morbidity was assessed by recording intraoperative complications, early postoperative complications (< 30 days), late complications (30–90 days), early hospital readmission (< 30 days), and early reoperation (< 30 days). Complication severity was graded according to the Clavien–Dindo classification, considering the highest-grade event per patient.
Oncological outcomes included need for adjuvant therapy, disease recurrence, and time to recurrence. Overall survival (OS) was defined as the time from radical cystectomy to death from any cause. Recurrence-free survival (RFS) was calculated from surgery to the first radiological or histological evidence of pelvic recurrence or distant metastasis. Cancer-specific survival (CSS) was defined as the time from surgery to death attributable to bladder cancer; deaths from other causes were censored.
Statistical analysis
Continuous variables were reported as mean ± standard deviation or median with interquartile range, as appropriate. Categorical variables were expressed as absolute numbers and percentages. All statistical tests were two-sided, with a 95% confidence interval adopted and p-values < 0.05 considered statistically significant.
Survival analyses were performed using the Kaplan–Meier method and Cox regression, comparing patients operated between 2005 and 2014 and 2015–2025 using the log-rank test to evaluate temporal changes in outcomes. Patients were censored at the date of last follow-up when applicable.
A multivariable logistic regression model including period, clinical stage, and nodal status was constructed a priori based on established prognostic relevance. All statistical analyses were conducted using standard statistical software.
Results
Patient population and baseline characteristics
A total of 733 patients underwent radical cystectomy with pelvic lymph node dissection during the study period. The mean age at surgery was 66 years, 69.2% men and 30.8% woman. Baseline clinical and pathological characteristics are summarized in Table 1.
Table 1.
Clinical and Epidemiological Characteristics of Patients
| Characteristics | 2005–2025 Total (n = 733) |
2005–2014 Total (n = 443) |
2015–2025 Total (n = 290) |
|---|---|---|---|
| Age at cystectomy (years), mean (SD) | 66.20 (10.68) | 66.98 (11.19) | 65.02 (9.77) |
| Gender, n (%) | 727 | 438 | 289 |
| Male | 503 (69.19) | 308 (70.32) | 195 (67.47) |
| Female | 224 (30.81) | 130 (29.68) | 94 (32.53) |
| BMI a (kg/m2), mean (SD) | 26.27 (5.35) | 26.57 (5.46) | 25.89 (5.20) |
| ASA b, n (%) | 645 | 358 | 287 |
| I | 17 (2.64) | 5 (1.40) | 12 (4.18) |
| II | 417 (64.65) | 259 (72.35) | 158 (55.05) |
| III | 206 (31.94) | 89 (24.86) | 117 (40.77) |
| IV | 4 (0.62) | 4 (1.12) | 0 |
| V | 1 (0.16) | 1 (0.28) | 0 |
| KPS c, n (%) | 421 | 135 | 286 |
| 40 | 1 (0.24) | 1 (0.74) | 0 |
| 50 | 8 (1.90) | 1 (0.74) | 7 (2.45) |
| 60 | 4 (0.95) | 1 (0.74) | 3 (1.05) |
| 70 | 29 (6.89) | 8 (5.93) | 21 (7.34) |
| 80 | 89 (21.14) | 36 (26.67) | 53 (18.53) |
| 90 | 201 (47.74) | 56 (41.48) | 145 (50.70) |
| 100 | 89 (21.14) | 32 (23.70) | 57 (19.93) |
| ECOG d, n (%) | 420 | 133 | 287 |
| 0 | 152 (36.19) | 61 (45.86) | 91 (31.71) |
| 1 | 208 (49.52) | 59 (44.36) | 149 (51.92) |
| 2 | 44 (10.48) | 9 (6.77) | 35 (12.20) |
| 3 | 13 (3.10) | 3 (2.26) | 10 (3.48) |
| 4 | 3 (0.71) | 1 (0.75) | 2 (0.70) |
| Smoking Status, n (%) | 643 | 358 | 285 |
| Non-smoker | 199 (30.95) | 124 (34.64) | 75 (26.32) |
| Smoker | 175 (27.22) | 95 (26.54) | 80 (28.07) |
| Former smoker | 269 (41.84) | 139 (38.83) | 130 (45.61) |
| ACCI e, n (%) | 280 | 45 | 235 |
| 0 | 1 (0.36) | 1 (2.22) | 0 |
| 1 | 2 (0.71) | 1 (2.22) | 1 (0.43) |
| 2 | 23 (8.21) | 7 (15.56) | 16 (6.81) |
| 3 | 43 (15.36) | 11 (24.44) | 32 (13.62) |
| 4 | 60 (21.43) | 8 (17.78) | 52 (22.13) |
| 5 | 71 (25.36) | 7 (15.56) | 64 (27.23) |
| 6 | 41 (14.64) | 4 (8.89) | 37 (15.74) |
| 7 | 15 (5.36) | 1 (2.22) | 14 (5.96) |
| 8 | 11 (3.93) | 0 | 11 (4.68) |
| 9 | 9 (3.21) | 4 (8.89) | 5 (2.13) |
| 10 | 3 (1.07) | 0 | 3 (1.28) |
| 11 | 1 (0.36) | 1 (2.22) | 0 |
| Previous abdominal surgery, n (%) | 631 | 358 | 273 |
| Yes | 79 (12.52) | 17 (4.75) | 62 (22.71) |
| No | 552 (87.48) | 341 (95.25) | 211 (77.29) |
| Diabetes mellitus, n (%) | 631 | 357 | 274 |
| Yes | 109 (17.27) | 54 (15.13) | 55 (20.07) |
| No | 522 (82.73) | 303 (84.87) | 219 (79.93) |
| Use of anticoagulant, n (%) | 285 | 44 | 241 |
| Yes | 21 (7.37) | 3 (6.82) | 18 (7.47) |
| No | 264 (92.63) | 41 (93.18) | 223 (92.53) |
| Use of antiplatelet agent, n (%) | 285 | 44 | 241 |
| Yes | 17 (5.96) | 1 (2.27) | 16 (6.64) |
| No | 268 (94.04) | 43 (97.73) | 225 (93.36) |
| Preoperative hydronephrosis, n (%) | 590 | 345 | 245 |
| Yes | 245 (41.53) | 151 (43.77) | 94 (38.37) |
| No | 345 (58.47) | 194 (56.23) | 151 (61.63) |
| Neoadjuvant chemotherapy, n (%) | 435 | 179 | 256 |
| Yes | 150 (34.48) | 37 (20.67) | 113 (44.14) |
| No | 285 (65.52) | 142 (79.33) | 143 (55.86) |
a BMI Body Mass Index, b ASA American Association of Anesthesiologists classification, c KPS Karnofsky Performance Scale, d ECOG Performance Status Scale, and e ACCI Age−adjusted Charlson Comorbidity Index
Missing data were observed, primarily attributable to older medical records and the retrospective nature of the study. In such cases, analyses were conducted using complete-case data only, in order to avoid dilution of the results. Accordingly, denominators were restricted to patients with complete information, thereby preventing distortion of estimates due to inclusion of cases with missing data, particularly given that the proportion of missing data exceeded 10% of the sample.
Most patients were classified as ASA II (64.7%). At diagnosis, 41.8% were former smokers and 27.2% were active smokers. An ACCI ≥ 7 was observed in 39 patients (13.9%). Preoperative hydronephrosis was identified in 245 patients (41.5%). Neoadjuvant chemotherapy was administered to 34.5% of patients.
Surgical outcomes and perioperative morbidity
Most procedures were performed via an open approach (95.8%), and the most common urinary diversion was an ileal conduit (83.3%). The median operative time was 300 min, and the median estimated blood loss was 1,000 mL. The mean number of removed lymph nodes was 23.4 ± 12.3, and the mean lymph node density was 0.59 ± 4.40. Surgical outcomes are detailed in Table 2.
Table 2.
Variables related to radical cystectomies
| Variables of the surgical procedure | 2005–2025 Total (n = 733) |
2005–2014 Total (n = 443) |
2015–2025 Total (n = 290) |
|---|---|---|---|
| Surgical technique, n (%) | 691 | 437 | 254 |
| Open | 662 (95.80) | 437 (100.00) | 225 (88.58) |
| Robotic | 28 (4.05) | 0 | 28 (11.02) |
| Videolaparoscopic | 1 (0.14) | 0 | 1 (0.39) |
| Hospital stay (days), median (IQR) | 10.16 (9.33) | 10.37 (8.46) | 10.00 (10.53) |
| Shunt created, n (%) | 656 | 396 | 260 |
| Bricker | 545 (83.08) | 333 (84.09) | 212 (81.54) |
| Neobladder | 69 (10.52) | 53 (13.38) | 16 (6.15) |
| Ureterostomy | 37 (5.64) | 6 (1.52) | 31 (11.92) |
| Double barrel | 5 (0.76) | 4 (1.01) | 1 (0.38) |
| Number of lymph nodes removed, mean (SD) | 23.40 (12.29) | 21.90 (11.73) | 25.48 (12.75) |
| Number of positive lymph nodes, median (IQR) | 0.00 (2.00) | 1.00 (3.00) | 0.00 (1.00) |
| Lymph node density (%) |
Mean (SD) 0.59 (4.40) |
Median (IQR) 0.00 (0.04) |
Median (IQR) 0.00 (0.03) |
| Intraoperative complications, n (%) | 414 | 192 | 222 |
| Yes | 225 (54.35) | 164 (85.42) | 61 (27.48) |
| No | 189 (45.65) | 28 (14.58) | 161 (72.52) |
| Surgery duration (minutes) |
Median (IQR) 300.00 (160.00) |
Mean (SD) 343.79 (101.23) |
Median (IQR) 300.00 (160.00) |
| Blood loss (mL) |
Median (IQR) 1000.00 (900.00) |
Median (IQR) 1100.00 (1150.00) |
Mean (SD) 1002.86 (712.77) |
| Total postoperative complications, n (%) | 373 | 89 | 284 |
| Yes | 198 (53.08) | 44 (49.44) | 154 (54.23) |
| No | 175 (46.92) | 45 (50.56) | 130 (45.77) |
| Early complications (< 30 days), n (%) | 340 | 72 | 268 |
| Yes | 174 (51.18) | 34 (47.22) | 140 (52.24) |
| No | 166 (48.82) | 38 (52.78) | 128 (47.76) |
| Early hospital readmission (< 30 days), n (%) | 254 | 38 | 216 |
| Yes | 46 (18.11) | 1 (2.63) | 45 (20.83) |
| No | 208 (81.89) | 37 (97.37) | 171 (79.17) |
| Early reoperation (< 30 days), n (%) | 223 | 38 | 185 |
| Yes | 43 (19.28) | 5 (13.16) | 38 (20.54) |
| No | 180 (80.72) | 33 (86.84) | 147 (79.46) |
| Late complications (between 30 and 90 days), n (%) | 250 | 38 | 212 |
| Yes | 60 (24.00) | 4 (10.53) | 56 (26.42) |
| No | 190 (76.00) | 34 (89.47) | 156 (73.58) |
| Clavien-Dindo classification of the last complication, n (%) | 48 | 6 | 42 |
| 1 | 8 (16.67) | 0 | 8 (19.05) |
| 2 | 24 (50.00) | 2 (33.33) | 22 (52.38) |
| 3 | 8 (16.67) | 4 (66.67) | 4 (9.52) |
| 4 | 2 (4.17) | 0 | 2 (4.76) |
| 5 | 6 (12.50) | 0 | 6 (14.29) |
Intraoperative complications occurred in 54.4% of patients. Early postoperative complications were observed in 174 patients (51.2%), and 43 (19.3%) required early reoperation. Late complications occurred in 60 patients (24.0%). The most frequent highest-grade complication was Clavien–Dindo II (50%).
Between 2005 and 2014, 438 patients underwent radical cystectomy, compared with 295 between 2015 and 2025. Data on overall postoperative complications were available for 122 patients in the earlier cohort and for 285 patients in the later cohort. Among evaluable cases, 57 of 122 patients (46.7%) in the 2005–2014 period experienced at least one postoperative complication, as compared with 112 of 285 patients (39.3%) in the 2015–2025 period.
Histopathology and oncological outcomes
Urothelial carcinoma was the predominant histological subtype (80.4%). Locally advanced disease was present in 50.9% of patients, while 69.5% had no lymph node involvement, and 62.0% had no lymphovascular invasion. Adjuvant treatment was prescribed for 38 patients (14.2%), and tumor recurrence occurred in 279 patients (40.3%) (Table 3).
Table 3.
Histopathological characteristics and oncological outcomes of bladder cancer patients undergoing radical cystectomy
| Histopathology and oncological outcomes | Total (n = 733) |
|---|---|
| Postoperative tumor staging, n (%) | 666 |
| pT0 | 82 (12.31) |
| pTa | 34 (5.11) |
| pTis | 15 (2.25) |
| pT1 | 85 (12.76) |
| pT2 | 111 (16.67) |
| Locally advanced tumor | 339 (50.9) |
| Postoperative lymph node staging, n (%) | 658 |
| pN0 | 457 (69.45) |
| pN+ | 175 (26.59) |
| pNx | 26 (3.95) |
| Lymphovascular invasion, n (%) | 500 |
| Yes | 190 (38.00) |
| No | 310 (62.00) |
| Cancer in situ, n (%) | 467 |
| Yes | 122 (26.12) |
| No | 345 (73.88) |
| Adjuvant treatment, n (%) | 268 |
| Yes | 38 (14.18) |
| No | 230 (85.82) |
In multivariable Cox regression analysis for overall survival, including relevant clinical and pathological variables, treatment period remained independently associated with improved survival (HR 0.75, 95% CI 0.58–0.97; p = 0.029). Clinical stage was independently associated with overall survival (overall p = 0.046), with advanced clinical stage demonstrating a significantly increased hazard of death (HR 1.48, 95% CI 1.08–2.02; p = 0.015).
In the survival analysis, patients operated between 2015 and 2025 had significantly better outcomes than those operated between 2005 and 2014. Overall survival was higher in the more recent cohort (p < 0.001; 95% CI 5.51–8.48), as was cancer-specific survival (p < 0.0001; 95% CI 6.44–9.55). Recurrence-free survival also improved significantly (p < 0.001; 95% CI 8.49–11.50). Kaplan–Meier curves are shown in Figs. 1, 2 and 3.
Fig. 1.
Overall survival of bladder cancer patients undergoing radical cystectomy. p-value < 0.001 – Confidence Interval (95%) 5.51–8.48
Fig. 2.
Cancer-specific survival of bladder cancer patients undergoing radical cystectomy. p-value < 0.0001 – confidence interval (95%) 6.44–9.55
Fig. 3.
Recurrence-free survival of bladder cancer patients undergoing radical cystectomy. p-value < 0.001 – confidence interval (95%) 8.49–11.50
Discussion
Our study demonstrates a significant improvement in overall survival of patients undergoing radical cystectomy over a 20-year period in a tertiary oncological center in Latin America, reflecting the progressive evolution of perioperative care, institutional organization, and multidisciplinary management of bladder cancer. Similar temporal improvements have been reported in large contemporary series from high-volume centers, where structured care pathways and guideline adherence were associated with improved oncological outcomes [11]. To our knowledge, this represents the largest single-center Latin American cohort with the longest follow-up evaluating oncological outcomes after radical cystectomy.
One of the most significant institutional changes during the study period was the implementation of a structured, managed-care pathway for patients undergoing radical cystectomy. This initiative was designed to minimize delays in care, given the well-established association between prolonged time from diagnosis to definitive treatment and increased mortality [12]. Within this model, a predefined and coordinated schedule for staging investigations, multidisciplinary consultations, neoadjuvant chemotherapy when indicated, and surgical intervention was systematically optimized to streamline care delivery and reduce treatment latency.
Multidisciplinary care is provided from diagnosis through definitive treatment. Cases are systematically discussed in tumor board meetings involving urologists, medical oncologists, radiation oncologists, radiologists, geriatricians, and intensive care specialists, allowing integrated decision-making that considers oncologic, functional, and patient-related factors. Multidisciplinary fast-track models have been shown to reduce treatment delays, improve adherence to neoadjuvant chemotherapy, and optimize perioperative preparation, all of which are associated with improved survival outcomes in muscle-invasive bladder cancer [13].
The routine adoption of Enhanced Recovery After Surgery (ERAS) for radical cystectomy protocols was fully implemented after 2014 and likely contributed to the observed survival gains. ERAS implementation following radical cystectomy has been consistently associated with reduced postoperative morbidity, shorter length of hospital stay, and accelerated functional recovery, without compromising oncologic outcomes [14].
All patients were managed postoperatively in the intensive care unit during the first 48 h, ensuring standardized hemodynamic monitoring and early detection of potential complications.
The increased use of cisplatin-based neoadjuvant chemotherapy, together with improved coordination between systemic therapy and surgery, represents another key factor underlying improved outcomes. Meta-analyses and real-world data demonstrate that neoadjuvant chemotherapy confers a survival benefit, and recent evidence highlights that delays between completion of chemotherapy and cystectomy negatively impact survival, emphasizing the importance of streamlined care pathways [15, 16].
In this institutional series, the ileal conduit was the predominant form of urinary diversion (83.3%), followed by orthotopic neobladder and cutaneous ureterostomy. It is well established that different diversion types are associated with distinct morbidity patterns, with ileal conduits more frequently related to stoma and ureter enteric complications, whereas orthotopic neobladders may present higher rates of functional and metabolic disturbances. Contemporary series reinforce that diversion choice influences both early and late complication profiles and requires careful patient selection [17, 18]. In our cohort, the open approach was the predominant surgical access, accounting for 95.8% of cases (Table 2). The robotic approach was introduced only three years ago for radical cystectomy. Compared with contemporary high-volume series from North America and Europe, early complications occurred in 51.2% of patients in our cohort, as compared with 69.1% in the North American series reported by Ben-David et al. [20] and 57% in the European cohort described by Arora et al. [21]. The European study demonstrated a comparable early complication rate, whereas the higher incidend has been performed exclusively within a research protocol, given that our institution is a public healthcare center in a country where robotic radical cystectomy currently lacks governmental financial reimbursement.
Therefore, it is unlikely that the observed paradigm shift in patient care can be attributed primarily to changes in surgical approach. This interpretation is consistent with evidence from randomized trials and high-quality meta-analyses demonstrating no statistically significant differences in overall postoperative complication rates between robotic-assisted and open radical cystectomy [19].
The change in systemic treatment with the new immunotherapy regimens associated with ADC and perioperative treatment, as well as new biomarkers, may play a role in improving the quality of life of patients undergoing this new management, in an analogous way to what we see in our comparative cohort [22–24]
Late complications were observed in 24.0% of patients in our Latin American cohort, as compared with 31.6% in the North American series and 61.6% in the European cohort. Our institution performs a mean of 36.6 radical cystectomies per year, whereas the European and North American centers report annual volumes of 25 and 22 cases, respectively. Surgical volume is consistently associated with postoperative morbidity, which may partly account for the differences in complication rates across studies [9].
Despite a higher prevalence of locally advanced disease (pT3–pT4, 50.9% vs. 25.8%) and nodal positivity (26.6% vs. 8.1% in the North American cohort and 19% in the European series), morbidity outcomes in our study were not inferior. These findings suggest that institutional expertise and structured perioperative pathways can yield outcomes comparable to those of established high-volume centers, even within a middle-income setting.
Notwithstanding the strengths of our large single-center cohort and extended follow-up, several limitations should be considered. First, the retrospective design inherently exposes the study to selection bias, information bias, and residual confounding, despite predefined variables and multivariable adjustment. Furthermore, the 20-year study period encompassed a transition from paper-based to electronic medical records, which may have affected data completeness with a large number of missing data and variable granularity, particularly in the earlier cohort. Lastly, a temporal follow-up bias must be acknowledged, given the shorter observation period in the contemporary cohort (mean 22 months) compared with the earlier cohort (mean 30 months).
Additionally, as a single-center study conducted in a tertiary referral institution, our findings may be influenced by referral bias and may not be fully generalizable to lower-volume centers. The minimally invasive approach (robotic and laparoscopic) represented less than 5% of the total cases, limiting any meaningful comparative assessment between surgical techniques and reducing its potential impact on overall outcomes. Temporal improvements in outcomes likely reflect multiple concurrent institutional changes—such as ERAS implementation, increased use of neoadjuvant chemotherapy, and multidisciplinary care—making it difficult to isolate the independent effect of any single intervention. Finally, although survival analyses were adjusted for major clinical and pathological factors, unmeasured confounders and changes in perioperative technology over time may also have contributed to the observed improvements.
Despite limitations related to the retrospective design, single-center nature, missing data, and regional population, our findings demonstrate that meaningful survival gains can be achieved through system-level organization, multidisciplinary care, and evidence-based perioperative protocols. These results reinforce the importance of centralizing radical cystectomy in specialized centers and investing in coordinated oncological care.
Conclusion
The centralization of muscle-invasive bladder cancer management in tertiary oncology centers, combined with the implementation of structured perioperative protocols, integrated multidisciplinary care, and optimization of care pathways, has substantially contributed to improved clinical outcomes over the past two decades. The observed reductions in mortality and increases in survival following radical cystectomy underscore the importance of evidence-based institutional strategies in enhancing the quality of oncologic surgical care.
Acknowledgements
Not applicable.
Abbreviations
- MIBC
Muscle-invasive bladder cancer
- BCG
Bacillus Calmette-Guérin
- WHO
World Health Organization
- AJCC
American joint committee on cancer
- EAU
European Association of Urology
- BMI
Body mass index
- ASA
American society of anesthesiologists score
- KPS
Karnofsky performance status
- ECOG
Eastern cooperative oncology group performance status
- ACCI
Charlson comorbidity index
- OS
Overall survival
- RFS
Recurrence-free survival
- CSS
Cancer-specific survival
- ERAS
Enhanced recovery after surgery
Authors’ contributions
All authors contributed to data collection, study conception and design, and manuscript preparation. All authors participated in the writing and critical revision of the article and approved the final version for submission.
Funding
This research received no specific grant from any funding agency.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was reviewed and approved by the Institutional Research Ethics Committee under approval number CCEP: 5063/24. Due to the retrospective nature of the study and the use of anonymized data obtained from medical records, the requirement for informed consent was waived. All procedures were conducted in accordance with the ethical standards of the institutional committee and with the principles of the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.