Role of Radical Cystectomy in Metastatic Bladder Cancer

Background/Objectives: The role of radical cystectomy (RC) in clinically metastatic (cM+) bladder cancer is unclear. This study aimed to identify national clinical practice patterns, factors associated with receipt of RC, and survival outcomes among patients with cM+ bladder cancer before the immunotherapy and antibody–drug conjugate era. Methods: In this retrospective cohort study, 18,360 patients with cM+ bladder cancer were identified from the National Cancer Database between 2006 and 2016. Demographics, comorbidities, cancer stage, and surgical outcomes were compared between patients who received RC and those managed without cystectomy (No RC). Multivariable logistic regression was used to identify factors associated with receiving RC, and overall survival was evaluated with Kaplan–Meier analysis and a multivariable Cox model with time measured from diagnosis, adjusted for age, sex, race, Charlson Comorbidity Index (CCI) score, clinical T stage, and histology. Results: Among the 18,360 patients with cM+ bladder cancer, 987 (5.4%) underwent RC. Patients who underwent RC were significantly younger, more likely to be White, and had lower CCI scores. Utilization of RC remained stable throughout the study period. On multivariable logistic regression, increasing age, Black race, and CCI score ≥ 3 were associated with lower odds of receiving RC, whereas cT3/4 disease and urothelial histology were predictors of receiving RC. Kaplan–Meier analysis demonstrated higher overall survival in the RC group. Postoperative mortality was 4.6% at 30 days and 23.6% at 90 days. Conclusions: Radical cystectomy was infrequently performed among patients with cM+ bladder cancer and was concentrated among younger, healthier patients. The survival difference between groups reflects selection and cannot be interpreted as a causal survival benefit from RC, since surgical intent, metastatic burden, and postoperative disease status are unavailable. Our findings provide a descriptive, population-level reference for comparison with future studies of RC in the current treatment era.