A multicenter retrospective study published on September 8, 2026, in Clinical Genitourinary Cancer examined the association between preoperative kidney function and recurrence-free survival and overall survival in patients with muscle-invasive bladder cancer undergoing radical cystectomy. Kidney function was assessed using the 2021 CKD-EPI estimated glomerular filtration rate and measured 24-hour creatinine clearance.
Title:“Preoperative Renal Impairment and Oncological Outcomes after Radical Cystectomy: A Multicenter Cohort Study”.
Authors: Sebastian Lenart, David Augustin, Gerald Klinglmair, Josef Fritz, Alfred Hobisch, Andreas Berger, Balazs Odler, Andreas Kronbichler, Sabine Ludwig, and Renate Pichler.
Why Renal Function Matters
Kidney function is an important consideration in muscle-invasive bladder cancer, particularly because impaired renal function can affect eligibility for cisplatin-based neoadjuvant chemotherapy.
Several retrospective studies have previously reported poorer oncological outcomes among patients with reduced kidney function undergoing radical cystectomy. However, it has remained unclear whether renal impairment itself carries independent prognostic value or whether it reflects other unfavorable clinical and pathological characteristics, as well as differences in treatment selection.
The study therefore assessed recurrence-free survival and overall survival according to preoperative renal function measured by both CKD-EPI eGFR and 24-hour creatinine clearance.
Study Design
The analysis included 396 patients with histologically confirmed muscle-invasive bladder cancer who underwent radical cystectomy between January 2009 and May 2023 at the Medical University of Innsbruck and Academic Teaching Hospital Feldkirch.
The mean age was 67.2 years, and 318 patients, or 80.3%, were male. Neoadjuvant chemotherapy was given to 121 patients, representing 30.6% of the cohort. At final pathology, 112 patients, or 28.3%, had ≥pT3 disease, while 55 patients, or 13.9%, had pathological nodal involvement. During a mean follow-up of 51.2 months, 121 patients developed recurrence and 107 died.
Preoperative renal impairment was defined as an eGFR below 60 mL/min/1.73 m² or a measured creatinine clearance below 60 mL/min. Because longitudinal measurements demonstrating persistence for at least three months were unavailable, the authors used the term preoperative renal impairment rather than confirmed chronic kidney disease. Renal impairment was identified in 63 of 396 patients, or 15.9%, by CKD-EPI eGFR and in 51 of 318 evaluable patients, or 16.0%, by measured creatinine clearance.
Renal Impairment and Disease Characteristics
Patients with eGFR below 60 mL/min/1.73 m² were older and more often had adverse pathological features. Compared with patients with preserved eGFR, they had higher rates of ≥pT3 disease, 52.4% versus 23.7%, pN-positive disease, 25.4% versus 11.7%, and lymphovascular invasion, 42.9% versus 15.3%. Neoadjuvant chemotherapy was also used less often in patients with renal impairment, 14.3% versus 33.6%.
Survival Outcomes by Renal Function
Before adjustment for other prognostic factors, impaired renal function was associated with worse recurrence-free survival and overall survival with both renal function measures.
Among patients with eGFR below 60 mL/min/1.73 m², 5-year recurrence-free survival was 45.4%, compared with 74.0% among those with preserved eGFR. Five-year overall survival was 56.9% versus 78.5%, respectively. The same trend was seen with measured creatinine clearance. Five-year recurrence-free survival was 58.7% in patients with creatinine clearance below 60 mL/min and 71.9% in those with values of at least 60 mL/min. Five-year overall survival was 66.9% versus 77.6%.
In univariable Cox regression, eGFR-defined renal impairment was associated with worse recurrence-free survival, with an HR of 2.92, and worse overall survival, with an HR of 2.64. For measured creatinine clearance below 60 mL/min, the corresponding HRs were 1.90 for recurrence-free survival and 1.95 for overall survival.
Adjusted Survival Analysis
After adjustment for age and sex, eGFR-defined renal impairment remained associated with recurrence-free survival, with an HR of 2.37, and overall survival, with an HR of 1.91. The associations were attenuated after further adjustment for pathological stage, nodal status, lymphovascular invasion, urinary diversion, and neoadjuvant chemotherapy, and were no longer statistically significant.
For eGFR below 60 mL/min/1.73 m², the fully adjusted HR was 1.29 for recurrence-free survival and 1.36 for overall survival. For measured creatinine clearance below 60 mL/min, the fully adjusted HR was 0.95 for both endpoints. When kidney function was analyzed as a continuous variable, the results followed the same pattern: associations seen in less-adjusted models were attenuated after full adjustment and were no longer statistically significant.
Is Renal Function an Independent Prognostic Factor?
The results suggest that impaired renal function may, at least partly, reflect other unfavorable clinical and pathological features, while its independent prognostic contribution remains uncertain.
The authors noted that impaired kidney function may reduce eligibility for cisplatin-based neoadjuvant chemotherapy. At the same time, locally advanced bladder cancer may itself impair renal function through urinary tract obstruction. These overlapping factors make it difficult to determine the direction of the association in a retrospective study, and the analysis cannot establish an independent or causal effect of renal impairment on oncological outcomes.
The two methods used to assess kidney function also showed only moderate correlation. The Pearson correlation coefficient between CKD-EPI eGFR and measured 24-hour creatinine clearance was 0.497. Agreement between the two measures when classified using the respective 60 mL/min thresholds was also moderate, with a Cohen’s kappa of 0.409.
Limitations
The retrospective design leaves the study vulnerable to residual confounding and selection bias. Several potentially relevant factors were not consistently available, including hydronephrosis, the underlying cause and chronicity of renal dysfunction, ECOG performance status, frailty, comprehensive comorbidity measures, cardiovascular disease, diabetes, smoking exposure, and nutritional status.
Lymphovascular invasion status was unknown in 41.9% of patients. The number of patients with renal impairment and the number of outcome events were also limited, resulting in wide confidence intervals that could not exclude clinically meaningful residual associations.
In addition, eGFR and measured creatinine clearance were not obtained uniformly at the same time, and 24-hour urine collections are susceptible to measurement error. The authors also noted that adjustment for pathological stage, neoadjuvant chemotherapy, and urinary diversion could represent partial overadjustment if these variables are part of the pathway linking renal impairment with survival.
Key Takeaways
Preoperative renal impairment was associated with inferior recurrence-free survival and overall survival in unadjusted analyses after radical cystectomy. However, the associations were substantially attenuated after adjustment for pathological and treatment-related factors, and an independent prognostic effect of preoperative renal impairment could not be demonstrated.
The prognostic relevance of baseline kidney function therefore remains uncertain and warrants further study in contemporary cohorts receiving current perioperative systemic therapies.
The full article is available in Clinical Genitourinary Cancer.
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