The BladderPath trial and bladder MRI: what's next?

Bladder cancer is the 7th most common cancer in men and the 10th most common overall. Approximately 75% of cases are non-muscle-invasive (Ta, CIS, T1), while the remaining 25% are muscle-invasive (≥ T2). Accurate local staging is crucial for treatment decisions and patient prognosis [1]. The introduction of the Vesical Imaging-Reporting and Data System (VI-RADS) has revolutionized bladder cancer staging, offering greater accuracy and a less invasive alternative to TURBT [2]. Various systematic reviews and meta-analyses have confirmed its high diagnostic accuracy and inter-reader agreement, supporting its clinical adoption [3]. Despite these advancements, a major limitation in bladder cancer management remains the delayed pathway for patients with muscle-invasive bladder cancer (MIBC). The BladderPath trial directly addresses this issue by assessing the feasibility of omitting TURBT in a subset of patients and instead using multiparametric MRI (mpMRI) as the primary staging tool [4]. BladderPath was an open-label, randomized controlled trial conducted across 17 UK hospitals, focusing on feasibility and time to correct treatment (TTCT). Treatment-naïve patients requiring TURBT were randomly assigned to one of two pathways: Pathway 1 (TURBT-staged): Patients underwent TURBT as the standard of care. Pathway 2 (mpMRI-staged): Patients with probable NMIBC (Likert 1–2) proceeded to TURBT, whereas those with possible MIBC (Likert 3–5) underwent mpMRI followed by biopsy or urine cytology.