Search Results (470)

Background/Objectives: Intravesical therapy is associated with a range of side effects. This study assessed baseline self-reported health-related quality of life (HRQoL) scores and examined associations with clinical and demographic variables, as well as lower urinary symptom severity and bother scores, among individuals diagnosed with high-risk non-muscle invasive bladder cancer (NMIBC) prior to initiating intravesical Bacillus Calmette–Guérin (BCG) therapy, either alone or in combination with Mitomycin. Methods: Baseline data were collected from 501 participants with high-risk NMIBC enrolled in the Australian and New Zealand Urogenital Clinical Trials Group (ANZUP) BCG + Mitomycin Clinical Trial, of whom 438 completed the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C 30, QLQ-NMIBC 24, and the International Prostate Symptom Scoring Tool (IPSS) prior to commencing intravesical treatment. We conducted descriptive and multivariate statistical analyses. We used hierarchical linear regression to examine associations between HRQoL (Global Health Status) and physical functioning, emotional functioning, sexual function, sexual intimacy, and the IPSS total and bother scores. Results: Participants were predominately male (82%), with a mean age of 74.9 years. Over half reported moderate urinary symptoms that affected quality of life. Emotional functioning (β = 0.411, p < 0.001) and physical functioning (β = 0.355, p < 0.001) were the strongest predictors of HRQoL after adjusting for covariates. Conclusions: Individuals diagnosed with high-risk NMIBC report notable physical and emotional concerns prior to commencing intravesical therapy. Targeted interventions may be required to optimise physical and psychological reserve before treatment. Full article

Background: The fibrovascular stalk is characteristic of papillary bladder tumors and may be visualized on MRI as the inchworm sign. Contrast-enhanced ultrasound (CEUS) may depict the same structure dynamically by demonstrating pedicle perfusion before tumor enhancement. We hypothesized that CEUS would be more sensitive than the MRI inchworm sign for detecting a histologically confirmed fibrovascular stalk and that stalk presence would be associated with non-muscle-invasive bladder cancer without completely excluding detrusor muscle invasion. Methods: This retrospective study assessed 80 consecutive patients with one focal bladder lesion; 69 patients with technically adequate imaging and an adequate TURBT reference standard were included in the final paired analysis. Dedicated retrospective rereads of anonymized stored CEUS cine loops and complete mpMRI datasets were independently performed by two experienced readers per modality, who were blinded to the other imaging modality, histopathology, and each other’s assessments. A blinded pathologist assessed fibrovascular stalk presence and detrusor muscle invasion. Paired performance was evaluated using exact McNemar testing. Results: Histopathology identified a stalk in 48 lesions. CEUS detected 46 of 48 stalks, and MRI detected 36, corresponding to sensitivities of 95.8% and 75.0%, specificities of 90.5% and 81.0%, and accuracies of 94.2% and 76.8%, respectively. Interobserver agreement was 94.2% for both signs, with almost-perfect agreement for the CEUS vascular stalk sign (κ = 0.86) and the MRI inchworm sign (κ = 0.88). For MIBC detection, overall CEUS impression and VI-RADS 4–5 showed sensitivities of 66.7% and 87.5% (paired p = 0.063), specificities of 88.9% and 68.9% (paired p = 0.004), and accuracies of 81.2% and 75.4% (paired p = 0.424), respectively. Conclusions: However, the two signs are not operationally equivalent because the MRI inchworm sign additionally requires preservation of the underlying muscular layer, a criterion that may have contributed to its lower observed sensitivity. The stalk strongly favored non-muscle-invasive disease but did not exclude detrusor invasion. CEUS provides complementary perfusion information, whereas MRI-based VI-RADS remains central to local staging. Full article

Background and Objectives: Radical cystectomy (RC) is standard treatment for muscle-invasive bladder cancer, but the role of gynecologic organ preservation in women remains uncertain. We primarily evaluated the prevalence and predictors of pathological gynecologic organ involvement and secondarily assessed survival and developed a prediction model. Materials and Methods: This multicenter retrospective study included 232 women undergoing RC at 13 tertiary centers. Of the 232 women, 182 had clinical T2 disease and 50 had BCG-unresponsive or very-high-risk Ta/T1 non-muscle-invasive bladder cancer. Overall survival (OS) was the primary endpoint; CSS and RFS were secondary outcomes. Multivariable logistic regression was used to identify predictors and develop preoperative prediction models. Results: Pathological gynecologic organ involvement was identified in 26 patients (11.2%): uterine in 15 (6.5%), vaginal in 11 (4.7%), ovarian in five (2.2%), and adnexal in 21 (9.1%). The median OS was shorter in patients with involvement than in those without (19.0 vs. 48.0 months; p = 0.048). Vaginal and ovarian involvement were associated with shorter OS (both p < 0.001), whereas uterine and adnexal involvement were not. Pathological T stage was associated with organ involvement (p = 0.001), with the highest frequency in pT4 disease. Model 2 showed an AUC of 0.898 and an optimism-corrected AUC of 0.872. A risk score of 0 classified 31.0% as low risk, with an NPV of 97.2% and a sensitivity of 92.3%. Conclusions: Pathological gynecologic organ involvement was uncommon but associated with poorer survival. These findings may support preoperative risk stratification, although the oncologic safety of organ-preserving surgery cannot be established from pathological involvement data alone. Full article

Background/Objectives: The ongoing Bacillus Calmette–Guérin (BCG) shortage, treatment intolerance, and BCG-unresponsive disease necessitate bladder-sparing alternatives for non-muscle-invasive bladder cancer (NMIBC). We reviewed the clinical evidence for hyperthermic intravesical chemotherapy (HIVEC). Methods: PubMed and PubMed Central were searched from inception to 15 March 2026 (updated 10 July 2026) for primary studies of device-assisted HIVEC in NMIBC. Studies reporting recurrence-free survival (RFS), progression, response, or safety were eligible. Records were screened and data extracted independently in duplicate, and risk of bias was assessed with RoB 2 (randomised trials), ROBINS-I (non-randomised comparative studies), and the Newcastle–Ottawa Scale (single-arm and registry cohorts). Outcomes were synthesised narratively within pre-specified clinical strata, with carcinoma in situ (CIS) analysed separately from papillary-only disease. Results: Twenty-four studies (>3600 patients), including seven randomised trials and a large multinational registry, were included. In BCG-naive or mixed-risk populations, 12-month RFS generally ranged from 78% to 98% and 24-month RFS from 57% to 88%; progression was uncommon. In BCG-unresponsive or BCG-failure disease, 24-month RFS was typically 40–60%, with poorer control in carcinoma in situ. Comparative studies mostly reported no statistically significant difference in RFS or progression versus BCG, but these analyses were predominantly retrospective or underpowered, and the single randomised signal favouring HIVEC over BCG was confined to a per-protocol analysis. Two randomised trials against non-heated mitomycin C (HIVEC-1 and HIVEC-II) found no recurrence benefit from hyperthermia, whereas an earlier randomised trial of radiofrequency thermochemotherapy reported a large long-term advantage over mitomycin C alone. Severe adverse events were infrequent, including approximately 2% in the largest series. Conclusions: HIVEC appears to be a tolerable bladder-sparing option in selected intermediate- and high-risk NMIBC. The available evidence is compatible with, but does not establish, equivalence or non-inferiority to BCG, because most comparative data are non-randomised, underpowered, and at moderate-to-serious risk of bias. Disease control after BCG failure is clinically meaningful but less durable, particularly in CIS. Adequately powered randomised trials reporting intention-to-treat outcomes are needed. Full article

Bacillus Calmette–Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) is a high-risk disease state for which early radical cystectomy remains the guideline-supported oncologic reference in surgically fit patients. Bladder-sparing therapy is necessary for patients ineligible for or declining cystectomy, but it is a preference-sensitive trade-off rather than an equivalent alternative: failure may permit high-grade recurrence, progression, and loss of a curative window. This targeted narrative review synthesizes the evidence for intravesical gemcitabine monotherapy, sequential gemcitabine–docetaxel, and the sustained-release gemcitabine intravesical system TAR-200/INLEXZO, updated through 4 August 2026. Because the review is not systematic and the evidence is dominated by single-arm and retrospective studies, cross-study comparisons are descriptive and establish neither superiority nor equivalence; many gemcitabine studies enrolled mixed BCG-failure cohorts that do not satisfy the contemporary definition. Gemcitabine monotherapy is active but shows declining disease control over time. Sequential gemcitabine–docetaxel has accumulated substantial multicenter observational experience, yet a 2026 retrospective comparison did not demonstrate improved high-grade recurrence-free survival over gemcitabine alone. TAR-200 achieved a centrally confirmed complete response at any time in 82.4% of patients, with a median duration of response of 25.8 months in the single-arm phase 2b SunRISe-1 study and is approved in the United States as INLEXZO for BCG-unresponsive carcinoma in situ with or without papillary tumors; no approved agent holds a papillary-only indication. Comparative patient-reported outcome evidence remains limited, and molecular markers, urinary tumor DNA and transcriptomic subtypes remain investigational rather than validated selection tools. Bladder-sparing treatment should therefore be phenotype- and label-aware, time-limited, and coupled to intensive surveillance with predefined triggers for cystectomy. Full article

Background: Definitions of BCG-unresponsive non-muscle-invasive bladder cancer (NMIBC) have become central to therapeutic decision making and clinical trial eligibility. This perspective synthesizes regulatory frameworks with real-world observations to examine how structural conditions shape the applicability of current definitions. These definitions rely on structural prerequisites—adequate BCG exposure, routine maintenance therapy, standardized surveillance, timely access to early radical cystectomy, and complete tumour-level documentation—that are not consistently achievable across diverse health-care environments. This study examines the structural and operational factors that limit the applicability of current BCG-unresponsive criteria in real-world NMIBC care. Methods: A multilevel analysis was performed and integrated four complementary sources of evidence—regulatory frameworks, national claims datasets, multicenter clinical studies, and real-world practice observation—selected for their ability to capture distinct structural dimensions of NMIBC care. Operational assumptions embedded in contemporary definitions were compared with real-world treatment patterns. Structural barriers were categorized across macro-level system constraints, meso-level institutional practices, and micro-level clinical workflows. Results: As a result, a substantial proportion of patients cannot be classified under existing criteria because the exposure-based and time-dependent conditions required by regulatory definitions are not met in routine practice. Maintenance BCG is infrequently delivered, surveillance intervals vary widely, early radical cystectomy is limited by system-level and institutional factors, and key tumour-level variables required for classification are often missing in large-scale datasets. As a result, many patients cannot be reliably classified using existing criteria—not because of tumour biology or clinician behavior, but because the structural assumptions underlying the definitions are unmet. Conclusions: Current BCG-unresponsive criteria rely on structural conditions that are not universally present in real-world NMIBC care. These findings suggest that context-specific operational definitions, together with complementary strategies such as improving guideline implementation, enhancing data completeness, standardizing surveillance practices, and strengthening healthcare infrastructure, may help align regulatory expectations with real-world practice and support equitable access to bladder-sparing therapies. Full article

Bladder cancer (BC) is a common urological malignancy that lacks the non-invasive biomarkers that would make it suitable for early diagnosis. Human alpha-satellite DNA (hASAT) is a tandemly repeated centromeric/pericentromeric DNA family associated with chromosomal stability and cancer-related genomic instability. We quantified extracellular hASAT (ec-hASAT) in plasma circulating cell-free DNA by nanoplate-based digital PCR in a pilot cohort including 29 BC-negative samples, 10 patients with non-muscle-invasive BC (NMIBC), and 7 patients with muscle-invasive BC (MIBC). Plasma ec-hASAT copy number was higher in patients with BC than in the BC-negative group (Mann–Whitney U test, p = 6.61 × 10⁻⁷). BC-negative samples ranged from 225 to 11,864 copies/µL plasma, whereas BC samples ranged from 1138 to 16,097 copies/µL plasma. ROC analysis yielded an AUC of 0.944 for discriminating BC from BC-negative samples. At an exploratory threshold of 2000 copies/µL plasma, sensitivity was 94.1% (16/17; exact 95% CI, 71.3–99.9%) and specificity was 89.7% (26/29; exact 95% CI, 72.6–97.8%). These preliminary data support plasma ec-hASAT as a candidate minimally invasive biomarker for BC detection, including NMIBC, and justify validation in larger prospective cohorts. Full article

T1 high-grade (T1HG) urothelial carcinoma of the bladder presents a persistent clinical challenge: despite uniform high-risk classification under EAU guidelines, BCG failure and disease progression rates range from 10% to 40% across published series. Standard clinicopathological variables do not adequately explain this heterogeneity. Three pathological parameters evaluable from routine TURBT specimens—T1 substaging by lamina propria invasion depth, tumour budding at the invasion front, and E-cadherin (CDH1) immunohistochemistry—share a common mechanistic basis in CDH1-driven partial epithelial-to-mesenchymal transition and may refine escalation-oriented risk stratification without requiring additional tissue or molecular testing. We conducted a narrative critical review of PubMed/MEDLINE (January 2000–February 2026; 28 included studies) to evaluate the quantitative evidence for each parameter, with emphasis on reproducibility and BCG-specific outcome data. T1 substaging carries the strongest evidence: pooled progression HR 3.29 (95% CI 2.39–4.51) across 36 studies (n = 6781), with BCG failure of 41% vs. 21% in a centralised BCG-treated registry cohort of 264 patients on multivariable analysis. Tumour budding shows consistent adverse associations in BCG-treated pT1 NMIBC; zero progression was observed in the low-budding subgroup in the only available BCG-specific full-text cohort. CDH1 IHC is directionally supportive but limited by scoring heterogeneity (I² = 63%). All three parameters are mechanistically coherent and assessable from routine TURBT slides. Prospective validation with pre-specified thresholds and standardised scoring protocols is required before clinical implementation can be recommended. Full article

Background/Objectives: Transurethral resection of bladder tumors (TURBT) is the standard for diagnosing and treating non-muscle-invasive bladder cancer. For lateral bladder wall tumors, obturator nerve stimulation can trigger sudden adductor contractions, raising the risk of perforation, hemorrhage, incomplete resection, and poor specimen quality. We evaluated the impact of obturator nerve block (ONB) on specimen quality and perioperative complications. Methods: In this single-center retrospective study, patients with lateral wall tumors treated by TURBT between October 2022 and December 2024 were divided into an ONB group (spinal anesthesia plus ONB) and a non-ONB group (spinal anesthesia alone). Specimen quality, perioperative complications, and 12-month recurrence were analyzed. Results: In this retrospective cohort of 219 patients (135 ONB, 84 non-ONB), high-quality specimens were more frequent with ONB (71.1% vs. 35.7%, p < 0.001). No perforations occurred with ONB versus 5 (6.0%) without (p = 0.008); hematuria (11.1% vs. 28.6%, p = 0.002) and 12-month recurrence (4.4% vs. 16.7%, p = 0.005) were also lower. Conclusions: ONB added to spinal anesthesia during TURBT for lateral wall tumors was associated with improved specimen quality and fewer perioperative complications. The lower recurrence rate should be considered hypothesis-generating, given the retrospective design and the small number of recurrence events; prospective studies are needed. Full article

Background/Objectives: Non-muscle invasive bladder cancer (NMIBC) is characterized by high recurrence rates despite appropriate treatment and surveillance. Identifying inexpensive and readily available biomarkers capable of improving risk stratification remains an important clinical challenge. The platelet-to-lymphocyte ratio (PLR), a marker of systemic inflammation, has emerged as a potential prognostic indicator in several malignancies. This study aimed to evaluate the association between preoperative PLR, tumor recurrence, and recurrence-free survival (RFS) in NMIBC patients treated with intravesical Bacillus Calmette–Guérin (BCG) or thermochemotherapy. Methods: This retrospective study included 153 patients diagnosed with NMIBC between January 2020 and January 2024. All patients underwent transurethral resection of bladder tumor (TURBT) followed by intravesical BCG (n = 123) or thermochemotherapy (n = 30). Preoperative PLR was calculated from complete blood counts obtained before surgery. Receiver operating characteristic (ROC) analysis was used to determine the optimal PLR cut-off value. Recurrence-free survival was evaluated using Kaplan–Meier survival analysis and Cox proportional hazards regression models. Results: During a mean follow-up period of approximately 19 months, recurrence was observed in 35.8% of patients treated with BCG and 30% of those treated with thermochemotherapy. ROC analysis demonstrated good discriminatory ability for recurrence prediction (AUC = 0.831, 95% CI: 0.761–0.901, p < 0.001) and identified an optimal PLR threshold of 120. Patients with elevated PLR values demonstrated higher recurrence rates and shorter recurrence-free survival. Kaplan–Meier analysis revealed a clear separation of survival curves according to PLR status. In multivariable Cox regression analysis, PLR > 120 remained independently associated with recurrence-free survival in the BCG group (HR = 2.703, 95% CI: 1.118–6.534, p = 0.027), whereas only a borderline association was observed in the thermochemotherapy group (HR = 23.265, 95% CI: 0.952–568.336, p = 0.054). Conclusions: Elevated preoperative PLR was associated with recurrence and recurrence-free survival in patients with NMIBC. The prognostic value of PLR appeared to be more pronounced in patients receiving intravesical BCG therapy. Given its low cost, accessibility, and ease of calculation, PLR may serve as a useful adjunctive biomarker for clinical risk stratification when used alongside established clinicopathological prognostic factors. Further prospective multicenter studies are required to validate these findings. Full article

Background: Urothelial carcinoma requires frequent surveillance because of its high recurrence rate, particularly in patients with non-muscle-invasive disease. Although cystoscopy remains the standard method for diagnosis and follow-up, it is invasive, costly, and associated with patient discomfort. Urinary biomarkers have emerged as potential tools for improving surveillance and reducing unnecessary cystoscopies. Methods: We performed a narrative review of studies published between 2017 and 2026 evaluating urinary biomarkers in urothelial carcinoma. Particular attention was given to assay mechanisms, diagnostic performance, clinical applications, and integration into surveillance techniques. Results: The most extensively studied biomarkers were Xpert Bladder Cancer Monitor, Bladder EpiCheck, ADXBLADDER, and Cxbladder. Most molecular assays demonstrated higher sensitivity than urinary cytology, particularly for the detection of high-grade recurrence. Reported negative predictive values frequently exceeded 95%, suggesting potential utility in identifying patients at low risk of clinically significant recurrence. Xpert Bladder Cancer Monitor and Bladder EpiCheck were supported by the largest body of surveillance evidence, whereas Cxbladder and mutation-enhanced platforms showed promise for risk stratification and individualized follow-up. Evidence supports the use of urinary biomarkers as adjuncts to cystoscopy rather than replacements. Conclusions: Modern urinary biomarkers provide clinically useful information during the surveillance of urothelial carcinoma, especially for excluding high-grade recurrence and assisting the interpretation of equivocal findings. Future biomarker-guided surveillance strategies may reduce the burden of cystoscopy while maintaining oncological safety. Further studies are required to improve specificity and sensitivity in order to fully integrate these biomarkers into diagnostic and follow-up protocols. Full article

Background/Objectives: Neoadjuvant cisplatin-based chemotherapy (NAC) followed by radical cystectomy (RC) is a standard treatment for cisplatin-eligible patients with muscle-invasive bladder cancer (MIBC), yet baseline tools to refine prognostic stratification remain limited. We aimed to develop and internally validate a clinicopathological nomogram integrating the neutrophil-to-lymphocyte ratio (NLR) to estimate event-free survival (EFS) in patients with MIBC treated with NAC. Methods: We retrospectively analyzed 210 patients with cT2–T4aN0–1M0 MIBC treated with cisplatin-based NAC at two Spanish institutions between 2010 and 2021. Candidate predictors included demographic, clinicopathological, and routine laboratory variables. A multivariable Cox model with backward selection based on the Akaike information criterion (AIC) was used to derive the final model, and internal validation was performed using 1000 bootstrap resamples. Results: Sex, age, prior non–muscle-invasive bladder cancer (NMIBC), and NLR were retained in the final nomogram. The model showed moderate discrimination, with a Harrell’s c-index of 0.60 and an optimism-corrected c-index of 0.58. The nomogram stratified patients into low-, intermediate-, and high-risk groups, with median EFS not reached, 47.5 months, and 18.0 months, respectively. High-risk patients also showed lower pathological complete response (pCR) rates. Conclusions: This exploratory nomogram integrates an accessible systemic inflammatory marker with baseline clinical variables to identify patients with poorer outcomes despite NAC. External validation in contemporary cohorts is warranted before clinical implementation. Full article

Nectin-4 has emerged as a clinically relevant target in muscle-invasive bladder cancer (MIBC), primarily because of its role in antibody–drug conjugate-based therapies. However, the broader biological context of Nectin-4 expression and its association with tumor-promoting signaling pathways in MIBC remain insufficiently characterized. In this single-institution study, Nectin-4 expression (H-score 0–300) was assessed by immunohistochemistry in two independent MIBC cohorts. Associations between Nectin-4 expression and key markers related to growth signaling, metabolic regulation, and inflammation were analyzed alongside clinicopathological characteristics. Nectin-4 expression was significantly higher in malignant tissue than in non-malignant tissue (p = 0.0016 and p = 0.0302, respectively). Nectin-4 expression was not associated with demographic or clinicopathological parameters; however, a trend toward lower expression in more advanced disease stages was observed. Significant positive correlations were identified between Nectin-4 expression and protein kinase B (p = 0.0004), cytoplasmic (p = 0.0115) and membranous somatostatin receptor 2 (p = 0.0125), insulin receptor substrate 1 (p = 0.03), and interleukin-1 receptor antagonist (IL-1RA; p = 0.0045). In contrast, a negative correlation was observed with the IL-1β/IL-1RA ratio (p = 0.0246). Although Nectin-4 expression was not significantly associated with cancer-specific or overall survival, a trend toward shorter relapse-free survival was observed in patients with lower Nectin-4 expression (p = 0.0531). In multivariate analysis, patient age, but not Nectin-4 expression, emerged as an independent prognostic factor. Although Nectin-4 expression does not appear to have independent prognostic value, its biological associations suggest that it reflects an integrated tumor-related signaling context. These findings support further investigation of Nectin-4 as part of rational, biology-driven therapeutic strategies in bladder cancer. Full article

Background. Accurate prediction of pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) in muscle-invasive urothelial bladder cancer (MIBC) remains an unmet clinical need. The neutrophil-to-platelet/hemoglobin-to-lymphocyte (NPLH) ratio, a composite hematologic index that reflects both systemic inflammation and nutritional oxygen-carrying capacity, has not been previously evaluated as a predictor of NAC response in this setting. Methods. We retrospectively analyzed 114 consecutive patients with MIBC (cT2–T4, N0–N3) who received accelerated MVAC (aMVAC) NAC followed by radical cystectomy at a single academic center. Pretreatment NPLH (calculated as [neutrophils × platelets]/[hemoglobin × lymphocytes]) was assessed as a predictor of pCR (ypT0N0) and tumor regression grade (TRG). Receiver operating characteristic (ROC) curve analysis, Mann–Whitney U test, and logistic regression were used. NPLH performance was compared to NLR and PLR. Results. pCR was achieved in 35 patients (30.7%). Median NPLH was significantly lower in pCR vs. non-pCR patients (33.9 [IQR 23.1–42.4] vs. 47.6 [IQR 30.7–90.4]; p = 0.0007). NPLH yielded an AUC of 0.700 (bootstrap 95% CI 0.596–0.794) for pCR prediction, numerically superior to NLR (AUC 0.645 [0.542–0.741]) and PLR (AUC 0.643 [0.533–0.747]); DeLong test: NPLH vs. NLR p = 0.079, NPLH vs. PLR p = 0.090. At the optimal cut-off of 44.5, NPLH demonstrated 80.0% sensitivity and 57.0% specificity. pCR rates declined progressively across NPLH quartiles: 48.3% (Q1) to 10.3% (Q4). On multivariate logistic regression, log-transformed NPLH was the only independent predictor of pCR (parsimonious model, OR 0.292, 95% CI 0.131–0.652; p = 0.003; EPV = 17.5). A positive correlation was observed between NPLH and TRG score (Spearman r = 0.284; p = 0.0022), with significant differences between TRG 1 and TRG 3 subgroups (p = 0.0036). Conclusions. Pretreatment NPLH is an independent predictor of pCR to aMVAC in MIBC and is numerically superior to NLR and PLR (DeLong p = 0.079). Consisting exclusively of standard complete blood count parameters, NPLH is readily available and inexpensive. This single-center exploratory study is hypothesis-generating and requires prospective external validation before clinical implementation. Full article

Background: Most bladder cancer cases present as non-muscle-invasive bladder cancer (NMIBC), with the course of multiple recurrences leading to stage progression to muscle-invasive bladder cancer (MIBC) in 10–20% of cases, which is associated with higher morbidity and mortality. Accurate histopathologic classification of bladder cancer remains important for patient management. Methods: This retrospective–prospective observational cohort study was conducted on 244 transurethral resection specimens. Immunohistochemistry assessed CK5/6, CK20, and apoptosis-inducing factor (AIF) using three representations: intensity, percentage of positive cells, and multiplicative score. Discrimination between NMIBC (pTa/pT1) and MIBC (≥pT2), and between low-grade (LG) and high-grade (HG) tumors, was evaluated using ROC/AUC analysis and logistic regression. The main analysis focused on cross-sectional marker performance in primary/non-recurrent tumors. Recurrent tumors were analyzed only as an exploratory subgroup. Tumors were also categorized into basal, luminal, mixed/double-positive, and double-negative phenotypes using thresholds of 10% for CK5/6 and CK20. Results: For stage discrimination, all three markers showed modest separation. The best-performing representation was CK5/6 intensity (AUC 0.641; lower in MIBC). For grade discrimination, the AIF score showed the highest performance (AUC 0.729, higher in HG). Combining markers improved model performance (NMIBC vs. MIBC: AUC 0.784; strict LG vs. HG: AUC 0.778). Using the 10% cutoff in non-recurrent tumors, mixed/double-positive tumors had the lowest MIBC proportion (6.0%) and double-negative tumors the highest (46.7%). Conclusions: CK5/6, CK20, and AIF provide modest discrimination between stages, with lower CK5/6 and CK20, and higher AIF, in MIBC. The AIF score shows the highest separation between grades and may serve as a useful non-proliferation marker for grading, particularly when interpreted alongside CK5/6 and CK20 in a simple immunohistochemical panel. Full article