AUA 2026: Debate: In 2026, MRI with VIRADS is Mandatory for the Staging and Therapeutic planning for Bladder Cancer

(UroToday.com) The American Urological Association's 2026 Annual Meeting, between May 15 – May 18, 2026 in Washington D.C., was host to the AUA-IBCG Bladder Cancer Forum. Drs. Patrick Hensley, Niyati Lobo and Maria Carmen Mir Debated if in 2026, MRI with VIRADS is Mandatory for the Staging and therapeutic planning for Bladder Cancer.

Dr. Lobo moderated the debate session and presented the case of a 50-year-old female smoker with no significant comorbidities who initially presented with visible hematuria. Evaluation demonstrated a 2 cm mixed papillary/solid tumor located at the trigone. Pre-TURBT imaging included bladder MRI showing a VI-RADS 4 lesion at the bladder base, while CT urography and chest imaging demonstrated organ-confined disease with normal upper urinary tracts. Initial TURBT revealed G3T1 disease with concomitant CIS, with limited but clear detrusor muscle identified in the specimen.

The patient subsequently underwent repeat resection with bladder neck biopsies, which demonstrated progression to T2 disease. She ultimately received neoadjuvant chemotherapy followed by radical cystectomy, pelvic lymph node dissection (PLND), and orthotopic neobladder reconstruction. Final pathology demonstrated pT2N0 urothelial carcinoma.

Dr. Mir began by noting that contemporary guidelines (EAU, NCCN) increasingly endorse the use of bladder MRI for local staging of bladder cancer, particularly using the VI-RADS framework. She highlighted a study that showed VI-RADS ≥4 demonstrates a pooled sensitivity of 0.78 and specificity of 0.94 for predicting MIBC across multiple centers.

Multiparametric MRI should ideally be performed before TURBT to allow for improved anatomical characterization and more accurate assessment of depth of invasion using the VI-RADS scoring system. However, she cautioned that strict adherence to appropriate MRI acquisition protocols remains mandatory, and that current bladder MRI data are not yet equivalent to the level of evidence established by landmark prostate MRI trials.

Moreover, Dr. Mir highlighted additional data supporting the accuracy of VI-RADS MRI for non-invasive staging of bladder cancer, particularly for identifying MIBC. She reviewed a cohort of 159 patients who underwent MRI prior to radical cystectomy, among whom approximately 30% had MIBC on final pathology. For prediction of MIBC, a VI-RADS 4 threshold demonstrated a sensitivity of 84%, specificity of 93%, negative predictive value (NPV) of 93%, and an AUC of 0.88. Meanwhile, VI-RADS 5 demonstrated lower sensitivity (51%) but markedly higher specificity (99%).¹

She further emphasized the utility of MRI for predicting extravesical extension. Among 149 patients with MIBC undergoing radical cystectomy, VI-RADS 5 achieved a sensitivity of 90%, specificity of 98%, NPV of 96%, and an AUC of 0.94, supporting its value for identifying locally advanced disease.¹

Dr. Mir further emphasized that the performance of VI-RADS has now been consistently validated across multiple systematic reviews and meta-analyses evaluating the prediction of MIBC. Across the analyses by Woo, Del Giudice, and Al-Qudimat, VI-RADS demonstrated strong and reproducible diagnostic performance, with sensitivities ranging from 83–89%, specificities from 84–90%, and AUC values consistently exceeding 0.91. She noted that these findings reinforce VI-RADS as a robust, reproducible, and reliable staging tool for the non-invasive assessment of bladder cancer invasion and prediction of MIBC across different institutions and study populations.²

Dr. Mir further emphasized that bladder MRI is not only a diagnostic staging modality, but also an important tool to improve clinical decision-making and optimize treatment pathways for patients with suspected MIBC. She highlighted data from the BladderPath study, which evaluated an MRI-directed pathway compared with the traditional TURBT-based staging approach. Using an MRI-directed strategy with mpMRI and tumor biopsy allowed selected patients with confirmed MIBC to proceed directly to definitive treatment while bypassing repeat staging TURBT. Importantly, the study demonstrated no evidence of harm or clinically significant misclassification despite concerns regarding false positives, which occurred in approximately 30% of cases.³

She further noted that MRI-directed staging significantly reduced treatment delays. In the traditional pathway, the median time to treatment was approximately 98 days, whereas the MRI-directed fast-track pathway reduced treatment time to just 53 days, translating into approximately 45 days saved for patients with invasive disease.

Another important point highlighted by Dr. Mir was that MRI is increasingly becoming essential for modern multidisciplinary bladder cancer care. She noted that beyond initial staging, MRI can meaningfully contribute to treatment planning across the continuum of disease management.

She emphasized that NAC-VI-RADS has also demonstrated prospective reliability, with reported specificity rates ranging from 76–81% for response assessment following neoadjuvant chemotherapy.

Importantly, MRI was shown to provide several practical advantages in multidisciplinary care, including:

• Improved surgical planning
• Better risk stratification and assessment of treatment response
• Enhanced radiation therapy planning

Dr. Mir addressed several common “myths” surrounding bladder MRI, emphasizing that the field remains a work in progress but is rapidly evolving. She acknowledged that MRI interpretation is operator-dependent and requires well-established acquisition protocols, similar to the evolution seen with prostate MRI. She also highlighted the importance of radiologist experience and dedicated VI-RADS quality reporting systems to improve consistency and reproducibility.

Importantly, she stressed that bladder MRI is not intended to replace TURBT, but rather to complement it and improve clinical decision-making. She further noted that while MRI is not yet universally available, healthcare systems should work toward integrating it into routine multidisciplinary workflows.

Dr. Mir also emphasized that no currently available modality is perfect. She pointed out that TURBT itself frequently understages disease, which is precisely why repeat TURBTs are often required. Likewise, pathology specimens may not always be fully representative, and CT imaging and emerging molecular biomarkers such as ctDNA and urinary DNA assays also have inherent limitations. Overall, she argued that bladder MRI should be viewed as an additional tool that can enhance staging accuracy and treatment planning rather than as a standalone replacement for existing approaches.

Dr. Mir concluded her presentation with several clear take-home messages. She emphasized that in 2026, bladder MRI with VI-RADS should no longer be considered optional, but rather a foundational component of modern bladder cancer management. According to Dr. Mir, MRI improves staging accuracy, optimizes clinical decision-making, and facilitates truly multidisciplinary and personalized patient care. She closed by stating that avoiding MRI in contemporary bladder cancer practice is no longer a conservative approach, but instead reflects outdated management paradigms.

Dr. Hensley began by emphasizing that current NCCN guidelines still support CT urography, rather than MRI, as the preferred imaging modality for abdominopelvic staging in bladder cancer. He noted that MRI currently serves more as a complementary modality and may be particularly useful in patients with poor renal function, contrast allergy, or when additional local staging characterization is required.

In NMIBC, MRI may be considered in addition to CT for sessile or high-grade tumors to improve local staging assessment, while in MIBC, it may also be performed alongside CT imaging.⁴

He highlighted that CT urography continues to outperform MRI for upper tract and nodal evaluation. For upper tract assessment, CT urography demonstrated sensitivity rates up to 96% and specificity up to 99%, compared with MRI sensitivity up to 69% and specificity up to 97%. Similarly, for nodal staging, CT achieved a sensitivity of up to 83% and a specificity of up to 100%, whereas MRI sensitivity reached up to 76% with a specificity of up to 96%.⁴

Moreover, Dr. Hensley emphasized that TURBT with histopathologic evaluation, not imaging alone, remains the gold standard for determining muscle invasion in bladder cancer. He pointed out that in approximately 50% of the published VI-RADS studies, TURBT itself served as the staging reference standard or “ground truth.”²

He further argued that a complete endoscopic TURBT provides several important advantages beyond staging alone, including assessment of lymphovascular invasion, variant histology, concomitant CIS, and T-stage substaging, while also providing adequate tissue for somatic mutation profiling and other downstream molecular analyses.

As a third major point, Dr. Hensley emphasized that transurethral resection is both a diagnostic and therapeutic procedure. While the therapeutic value of complete TURBT in NMIBC is well established, he argued that its importance in MIBC is frequently underappreciated. He reviewed data demonstrating that visibly complete TURBTs were associated with significantly improved oncologic outcomes compared with incomplete resections, including higher complete response rates and improved survival outcomes.

Importantly, he highlighted that complete endoscopic resection may improve response to trimodal therapy as well as neoadjuvant chemotherapy, reinforcing the concept that high-quality TURBT remains a critical component of bladder preservation and multimodal treatment strategies in MIBC.⁵

Dr. Hensley also reviewed the BladderPath trial, a randomized study comparing standard TURBT-based staging versus MRI-directed staging pathways in patients with suspected MIBC.³ He highlighted that the MRI-based approach allowed for earlier identification of muscle-invasive disease and facilitated more rapid initiation of neoadjuvant therapy. Importantly, among patients classified as likely MIBC by MRI, a substantial proportion ultimately proceeded directly to MIBC-directed therapy (n=11), supporting the clinical utility of MRI-guided treatment pathways. However, he also acknowledged that the study did not demonstrate an overall survival advantage for the MRI-directed approach.

Moreover, bladder MRI with VI-RADS has inherent limitations. It was emphasized that VI-RADS was specifically designed to answer a binary clinical question, the likelihood of detrusor muscle invasion (NMIBC versus MIBC), rather than provide detailed granular T-staging. As such, it cannot reliably distinguish between stages such as T2 and T3a disease. Additional challenges include location-dependent performance, with lower diagnostic accuracy reported for tumors involving the lateral bladder wall or ureteral orifice. Barriers to broader clinical adoption were also highlighted, including variability in MRI access, inconsistency across guideline recommendations, and limited cost-effectiveness data.

When comparing CT and MRI for bladder cancer staging, CT maintains several practical advantages, including lower cost, shorter acquisition time, broader availability, greater familiarity among radiologists, and the ability to simultaneously perform chest staging. These factors were highlighted as important considerations supporting the continued role of CT urography in routine clinical practice despite the growing adoption of bladder MRI and VI-RADS. 

Lastly, Dr. Hensley highlighted a contemporary multicenter study evaluating whether repeat TURBT remains necessary in high-risk NMIBC when the initial resection is performed using blue light cystoscopy. Among patients with high-grade T1 disease, only 4.2% were upstaged to MIBC at repeat TURBT in this contemporary series from high-volume centers. The analysis suggested that approximately 24 patients would need to undergo repeat TURBT to identify one patient ultimately upstaged to muscle-invasive disease, underscoring the relatively low rate of occult upstaging in the modern era.⁶

He subsequently posed an important clinical question to the audience: if a high-quality index TURBT demonstrates NMIBC, should clinicians trust MRI findings alone to upstage a patient to MIBC? The discussion highlighted the ongoing tension between imaging-based staging and histopathologic assessment, particularly in cases where management decisions may significantly change based on MRI interpretation alone.

• Niyati Lobo, MD, Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
• Patrick J. Hensley, MD, Society of Urologic Oncology Fellow, MD Anderson Cancer Center, Houston, TX
• Maria Carmen Mir, MD, PhD, FEBU, Urologic Oncologist at NYC Health +, New York City, NY.

References:

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