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The Gold standard treatment for muscle-invasive bladder cancer (MIBC) in medically fit patients is neoadjuvant chemotherapy (NAC), followed by radical cystectomy (RC), usually urethra-sparing. Swedish guidelines recommend yearly urethroscopies for 5 years post-RC to detect urethral recurrences (URs). Evidence is limited regarding optimal urethral surveillance in the NAC-era for patients with MIBC. The goal was to evaluate UR-frequency across NAC-response groups: complete response (CR), i.e. pT0N0M0, and Non-CR-responses (partial response, stable disease, and progressive disease), compared with cystectomy-only controls.

A multicenter retrospective cohort study including 241 patients with ≥T2 disease in clinical and/or pathological staging (post-RC), urothelial or mixed urothelial histology, and undergoing urethra-sparing cystectomy between 2010 and 2024. Data were retrieved from medical records and transferred into an ethically approved database. UR was biopsy-confirmed; time to UR was analyzed using Aalen-Johansen cumulative incidence functions with the Gray's test.

40% (50/123) of the NAC-patients were complete responders. Nine UR-events occurred (3.7%) in the total material. UR was observed in 3/123 (2.4%) NAC-treated and 6/118 (5.1%) in No-NAC patients (Gray's, p = 0.291). No UR occurred among complete responders to NAC (0/50) versus 3/73 in non-complete responders (Gray's, p = 0.150). Four UR-cases (44.4%) were symptom-detected (urethral bleeding).

The total absence of urethral recurrences in NAC- and RC-treated MIBC-patients with complete responses suggests that the current Swedish recommendation of yearly urethroscopies could be reviewed since a more individualized surveillance strategy based on NAC-response may reduce unnecessary procedures.