Real-world Perioperative Systemic Treatment Patterns and Outcomes in Patients with Urothelial Carcinoma Undergoing Radical Surgery

• NAC was common in MIBC (57.6%) but uncommon in UTUC (5.5%). • In MIBC, NAC use increased over time, whereas adjuvant therapy (Adj) remained stable. • After 2022 approval, Adj nivolumab predominated in MIBC but remained limited in UTUC. • In UTUC, Adj was modest (15.7%); nivolumab uptake remained limited (0.9%). To describe real-world perioperative systemic treatment patterns in patients with muscle-invasive urothelial carcinoma undergoing radical surgery in Japan. We conducted a descriptive study using two hospital-based databases. We included patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC) and those with upper urinary tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU) between April 2014 and September 2024. Perioperative regimens were classified as neoadjuvant chemotherapy (NAC) or adjuvant therapy (Adj; chemotherapy or nivolumab). We identified 1,165 patients with MIBC who underwent RC and 4,401 with UTUC who underwent RNU. In MIBC, 57.6% received NAC (gemcitabine–cisplatin [GC], 48.2%; gemcitabine–carboplatin [GCarbo], 9.4%) and 20.2% received Adj (GC, 10.3%; GCarbo, 3.0%; nivolumab, 4.1%; other, 2.8%). NAC use in MIBC increased over time, whereas the proportion receiving Adj remained stable. After Adj nivolumab approval (2022–2024), Adj composition shifted toward immunotherapy, with nivolumab accounting for 75.4% and a decline in chemotherapy. Regarding renal function, higher eGFR was associated with GC over GCarbo in NAC, whereas lower eGFR was associated with GCarbo or nivolumab in Adj care. In UTUC, NAC remained uncommon (5.5%) and was mainly GC, while Adj was more frequent (15.7%) and consisted of both GC and GCarbo in similar proportions; the increase in Adj nivolumab was limited (0.9%) and modest after approval. NAC is common in MIBC but uncommon in UTUC, and Adj is used less often. Adj nivolumab rapidly became the predominant component of Adj in MIBC after approval, but remained limited in UTUC.