Natural History of Histologically Non-Muscle Invasive VI-RADS 4-5 Bladder Cancer Lesions

Backround Non–muscle-invasive bladder cancer carries a high risk of recurrence despite standard treatment, underscoring the need for more reliable tools to guide risk-adapted management. Purpose: To evaluate the predictive value of the Vesical Imaging-Reporting and Data System (VI-RADS) for recurrence-free survival (RFS) in patients with primary non–muscle-invasive bladder cancer (NMIBC), and to assess its prognostic utility across different risk groups. Material and Methods: This retrospective cohort study included 142 patients with histologically confirmed primary NMIBC who underwent multiparametric MRI (mpMRI) with VI-RADS scoring prior to any surgical or intravesical intervention between December 2019 and July 2023. Patients were categorized based on the 2021 European Association of Urology (EAU) NMIBC risk classification. Kaplan-Meier survival analysis and Cox regression were used to evaluate RFS and its predictors. Results: During a mean follow-up of 48.1 months, 22 patients (15.5%) experienced recurrence, while 2 progressed to muscle-invasive disease. In multivariate analysis, VI-RADS scores (HR = 7.3; 95% CI, 3.046–17.54; p < 0.001) and body mass index (BMI) (HR = 2.7; 95% CI, 1.031–7.087; p = 0.043) were identified as independent predictors of RFS. Among intermediate- and high/very high-risk groups, patients with VI-RADS 4–5 had significantly worse RFS (p = 0.001 and p = 0.006, respectively). No significant association was observed in the low-risk group (p = 0.846). Conclusion: VI-RADS scoring on mpMRI performed at the primary diagnostic stage is a significant independent predictor of recurrence-free survival in NMIBC, particularly in intermediate- and high-risk patients. Incorporating imaging-based clinical staging such as VI-RADS into NMIBC prognostic models could enhance individualized surveillance and management strategies.