Perioperative outcomes following open radical cystectomy in the setting of locally advanced bladder cancer

Purpose: To compare the perioperative outcomes and long-term survivors between localized (organ-confined cT2N0M0) and locally advanced (cT3–4 and/or cN1–3,M0) bladder cancer in patients undergoing radical cystectomy and lymphadenectomy. Methods: We conducted a retrospective observational cohort study including 364 consecutive patients who underwent open RC with urinary diversion at a high-volume tertiary referral center between July 2016 and November 2024. Patients were stratified according to pathological stage into localized disease (pT0–T2N0) and locally advanced disease (pT3–T4 and/or N1). Perioperative outcomes were evaluated using multivariable regression models. Overall survival (OS) was analyzed with Cox regression and Kaplan–Meier estimates. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were assessed using Fine–Gray competing-risks models. Propensity score matching (PSM) was performed as a sensitivity analysis. Results: Among 364 patients, 203 had localized and 161 had locally advanced BCa. Locally advanced disease was associated with greater intraoperative blood loss (β 230 ml, 95% CI 89.9–370.3) and longer operative time (β 16.5 min, 95% CI 2.6–30.3), but postoperative complication rates were similar between groups. With a median follow-up of 54.9 months in localized and 36.4 months in locally advanced BCa, locally advanced disease was associated with significantly worse oncologic outcomes. Multivariable analyses confirmed higher risks of overall mortality (HR 3.40, 95% CI 2.40–4.81), recurrence (sHR 5.12, 95% CI 3.45–7.59), and cancer-specific mortality (sHR 2.26, 95% CI 1.43–3.59). Results were consistent after PSM. Conclusion: This study showed that, compared with localized disease, RC for locally advanced BCa was associated with similar 30-day mortality and major complication rates, but worse oncological outcomes. These findings support the perioperative feasibility of surgery in selected patients with locally advanced disease while underscoring their persistently poorer cancer prognosis.