Table 13. Variant histology specific recommendations.

Variant histology	Recommendation
Micropapillary, plasmacytoid, nested, clear cell and microcystic UC	In MIBC with VH, we recommend NAC to achieve pathologic downstaging prior to RC as a higher pathologic T stage at RC is associated with worse survival outcomes and there is evidence of survival benefit
	A longer period of surveillance after RC is also warranted
Sarcomatoid differentiation	We recommend NAC in MIBC due to evidence of survival benefit
Lymphoepithelioma-like UC	Where LELC constitutes the predominant histology in MIBC, we recommend NAC due to chemosensitivity and evidence of survival benefit in other variants
Squamous/glandular divergent differentiation	NAC is warranted in these tumors. Despite having similar pathologic response to NAC compared to conventional UC, they are more likely to present at a higher pathologic stage. Adjuvant chemotherapy should be considered as a therapeutic option due to evidence of worse OS in glandular differentiation when not administered

UC, urothelial carcinoma; MIBC, muscle invasive bladder cancer; VH, variant histology; NAC, neoadjuvant chemotherapy; RC, radical cystectomy; LELC, lymphoepithelioma-like carcinoma; OS, overall survival.