pT3–4/pN+/pT2+LVI model flags ~4× higher post-cystectomy recurrence risk, guiding longer-intense surveillance

In a retrospective European individual-patient registry study of 3196 patients with cT2–T4 N0M0 bladder cancer treated with radical cystectomy across 16 centers (1990–2024), investigators used a Classification and Regression Tree model based on post-op pathology (pT stage, pN stage, lymphovascular invasion [LVI], and other features) to stratify recurrence risk. The “High-Risk” group (pT3–4, pN+, or pT2+LVI) had worse 5-year recurrence-free survival than “Low-Risk” (37.8% vs 76.2%; HR 4.29, 95% CI 3.63–5.00; p<0.001) and was also prognostic for cancer-specific survival (subdistribution HR 5.80) and overall survival (HR 3.04) (all p<0.001). Landmark analyses suggested elevated conditional recurrence risk persists through year 4 post-RC, but for patients event-free at 5 years the risk converged (HR 1.37; p=0.3), supporting a de-intensification point—whereas current guideline follow-up is largely expert-opinion-based and typically front-loads imaging in the first 2–3 years with less clarity on how to adapt intensity by pathology-defined risk.