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Background Preoperative prediction of bladder cancer (BCa) recurrence risk is critical for individualized clinical management of BCa patients. Purpose To develop and validate a nomogram based on radiomics and clinical predictors for personalized prediction of the first 2 years (TFTY) recurrence risk. Study Type Retrospective. Population Preoperative MRI datasets of 71 BCa patients (34 recurrent) were collected, and divided into training (n = 50) and validation cohorts (n = 21). Field Strength/Sequence 3.0T MRI/T2‐weighted (T2W), multi‐b‐value diffusion‐weighted (DW), and dynamic contrast‐enhanced (DCE) sequences. Assessment Radiomics features were extracted from the T2W, DW, apparent diffusion coefficient, and DCE images. A Rad_Score model was constructed using the support vector machine‐based recursive feature elimination approach and a logistic regression model. Combined with the important clinical factors, including age, gender, grade, and muscle‐invasive status (MIS) of the archived lesion, tumor size and number, surgery, and image signs like stalk and submucosal linear enhancement, a radiomics‐clinical nomogram was developed, and its performance was evaluated in the training and the validation cohorts. The potential clinical usefulness was analyzed by the decision curve. Statistical Tests Univariate and multivariate analyses were performed to explore the independent predictors for BCa recurrence prediction. Results Of the 1872 features, the 32 with the highest area under the curve (AUC) of receiver operating characteristic were selected for the Rad_Score calculation. The nomogram developed by two independent predictors, MIS and Rad_Score, showed good performance in the training (accuracy 88%, AUC 0.915, P << 0.01) and validation cohorts (accuracy 80.95%, AUC 0.838, P = 0.009). The decision curve exhibited when the risk threshold was larger than 0.3, more benefit was observed by using the radiomics‐clinical nomogram than using the radiomics or clinical model alone. Data Conclusion The proposed radiomics‐clinical nomogram has potential in the preoperative prediction of TFTY BCa recurrence. Level of Evidence: 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2019;50:1893–1904.

DWI is superior to DCE MRI for differentiating recurrent bladder tumors from postoperative inflammation or fibrosis. DWI can be included in the follow-up MRI protocol after bladder cancer surgery.

Submucosal linear enhancement under the tumor base on DCE-MRI complements tumor stalk detection on DWI for differentiating stage T1 from stage T2 bladder urothelial carcinoma.

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