In patients suffering from pN1-3 cM0 BCa, carboplatin-based ACT might not improve overall survival (OS). The findings highlight the necessity for alternative therapies for cisplatin-ineligible patients.

• This retrospective analysis included 1,057 patients with pTany pN1-3 cM0 urothelial BCa treated with or without carboplatin-based ACT after radical cystectomy and bilateral lymph-node dissection.

• Of participants, 69 (6.5%) received carboplatin-based ACT, and post-propensity score matching, 244 total patients were identified in two cohorts that did not differ for baseline features.

• A median follow-up of 19 months revealed occurrence of death in 114 (46.7%) patients.

• Use of carboplatin-based ACT was not predictive of improved OS (hazard ratio [HR] 0.67).

• Multivariable Cox regression analyses showed the following as independent predictors of worse OS: increasing age at surgery (HR 1.02) and increasing number of positive lymph nodes (HR 1.06).