2026 AUA/SUO NMIBC guideline: Key updates for clinical practice

The management of non-muscle invasive bladder cancer (NMIBC) is rapidly evolving. A wave of new therapies for BCG–unresponsive disease has expanded options for clinicians while adding complexity to decisions about treatment sequencing, while emerging evidence on the behavior of high-grade disease and a growing number of urinary biomarkers are continuing to influence management decisions.

In September 2026, the American Urological Association (AUA), in partnership with the Society of Urologic Oncology (SUO), released the 2026 amendment to its Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer (NMIBC) Guideline in order to address questions that have emerged based on new evidence. The amended guideline includes 40 recommendations based on a comprehensive review of literature, with updates addressing risk stratification, pathologic terminology, biomarkers, surveillance strategies, and treatment options.

"As the treatment landscape for non-muscle invasive bladder cancer continues to evolve, it is essential that clinical guidance reflects the latest evidence," said Peter E. Clark, MD, chair of the guideline panel, in the AUA press release.² "This amendment provides clinicians with practical recommendations that support individualized decision-making while addressing emerging therapeutic approaches and ongoing advances in the field."

The following FAQs summarize the key recommendations and Clark's perspective on applying them in practice.

Listen to more insights from Dr. Clark on an episode of The UroOnc Minute here.

1. What does the amendment recommend for initial diagnosis and resection?

At resection, clinicians should thoroughly examine and document the entire urethra and bladder, perform complete visual resection when technically feasible, and obtain upper tract imaging (Clinical Principles). Patients with a history of NMIBC, normal cystoscopy, and cytology positive for high-grade urothelial carcinoma should undergo upper tract evaluation, random bladder biopsies, and prostatic urethral biopsies, with blue light cystoscopy (BLC) used when available (Expert Opinion).

2. When is repeat resection or a postoperative instillation recommended?

Repeat transurethral resection (TUR) within 6 weeks of the initial transurethral resection of bladder tumor (TURBT) should be performed for T1 disease (Strong Recommendation; Evidence Level: Grade B) and may be performed for high-grade Ta tumors (Conditional Recommendation; Evidence Level: Grade C). Patients with suspected or known low- or intermediate-risk disease should receive a single postoperative instillation of intravesical chemotherapy within 24 hours of TURBT, unless perforation or extensive resection is suspected (Moderate Recommendation; Evidence Level: Grade B).

3. How has risk stratification changed?

All high-grade Ta tumors, regardless of size, are now classified as high risk; previously, very small high-grade Ta tumors fell into the intermediate-risk category. According to Clark, studies have shown that any degree of high-grade disease probably behaves more like high-risk disease. The intermediate-risk category now essentially represents low-grade disease that is large, multifocal, or recurrent.

"That's really an important distinction to make because a lot of the subsequent guidelines then flow down those risk strata," Clark said.

Clinicians should continue to assign a clinical stage and risk group at each occurrence or recurrence (Moderate Recommendation; Evidence Level: Grade C).

4. What does the reclassification mean for managing intermediate-risk disease?

With intermediate-risk disease now limited to low-grade tumors, Clark said recurrence, rather than progression, is the primary concern.

“A lot of what the panel was considering was how [to] decrease the morbidity of all the various things you can do. Maybe you don't repetitively go to TURBT in an operating room for a disease where we know the primary issue is recurrence,” he noted.

Clinicians may administer a 6-week course of induction intravesical therapy (Conditional Recommendation; Evidence Level: Grade B). Complete responders to induction chemotherapy may receive maintenance therapy, and complete responders to induction BCG may be offered 12 months of maintenance BCG, as tolerated (Conditional Recommendations; Evidence Level: Grade C).

5. What bladder-preserving options are available for recurrent low-grade disease?

For recurrent low-grade NMIBC, clinicians may perform TUR/fulguration, use an intravesical chemoablative agent, or manage with active surveillance (Conditional Recommendation; Evidence Level: Grade C). For small papillary recurrences of low-grade Ta disease, surveillance and/or in-office fulguration or chemoablation may be offered as an alternative to TUR under anesthesia (Expert Opinion).

Clark said the panel emphasized "in-office fulguration and surveillance for really small [lesions], especially in older or sicker patients." He also highlighted mitomycin for intravesical solution (Zusduri), now FDA approved in this setting, which he said can be quite effective for recurrent low-grade Ta tumors.

6. What role do urinary biomarkers play under the amended guideline?

Clinicians may use biomarkers to assess and predict response to intravesical therapy and to adjudicate equivocal cytology (Expert Opinion) but should not use them in place of cystoscopy during surveillance (Strong Recommendation; Evidence Level: Grade B). In patients with a history of low-risk cancer and a normal cystoscopy, routine biomarker or cytology testing during surveillance is not recommended (Expert Opinion). Clark noted that cystoscopy still has a role, but pointed to an emerging use the guideline addresses more:

7. How should subtype histology influence treatment decisions?

An experienced genitourinary pathologist should review cases with any doubt about subtype histology, extensive divergent differentiation, or lymphovascular invasion (LVI) (Moderate Recommendation; Evidence Level: Grade C). If bladder sparing is considered, clinicians should perform a restaging TURBT within 4 to 6 weeks, and because upstaging rates are high, they should discuss early radical cystectomy (Expert Opinion). Clark noted that the response of these tumors to intravesical therapy is poorly characterized and that they generally carry a worse prognosis.

"If you see some of these alternative subtypes, I think a little lightbulb should go off and say, 'Hey, I really should be thinking more about cystectomy in this particular patient,' even though we know patients often don't want cystectomies. Nevertheless, that should be something that should be emphasized in that situation," he said.

8. What is new for high-risk disease involving the prostatic urethra?

The amendment adds guidance for high-risk disease involving the prostatic urethra. Patients with high-risk NMIBC in the prostatic urethra who decline radical cystectomy and elect intravesical therapy should undergo repeat TUR of the prostatic urethra to improve staging accuracy and optimize the efficacy of subsequent therapy (Expert Opinion). In intermediate- or high-risk patients with persistent or recurrent disease after intravesical therapy, clinicians may perform a prostatic urethral biopsy and upper tract evaluation before additional intravesical therapy (Conditional Recommendation; Evidence Level: Grade C).

9. When should radical cystectomy be offered?

Initial radical cystectomy should be offered to high-risk patients fit for surgery with persistent high-grade T1 disease on repeat resection, or T1 tumors with carcinoma in situ (CIS), LVI, or subtype histology (Moderate Recommendation; Evidence Level: Grade C). It should also be offered after BCG failure, including high-grade T1 disease after a single induction course or persistent or recurrent high-risk disease within 12 months of 2 induction cycles or maintenance (Moderate Recommendations).

Clark cited the prospective CISTO trial in which patients, largely with BCG-unresponsive disease, who underwent cystectomy did well and on some quality-of-life parameters felt better than those receiving alternative intravesical therapy.

10. What does the guideline recommend after BCG failure?

High-risk patients with persistent or recurrent Ta or CIS after a single induction course of BCG should be offered a second course (Moderate Recommendation; Evidence Level: Grade C). For persistent or recurrent high-grade disease within 12 months of adequate BCG (2 induction courses, or 1 induction course plus 2 maintenance treatments) in patients unwilling or unfit for cystectomy, clinicians should recommend alternative intravesical immunotherapy or chemotherapy, systemic immunotherapy, or clinical trial enrollment (Moderate Recommendation; Evidence Level: Grade C). Clark called the growing list of BCG-unresponsive options the most confusing area for clinicians. Those he cited include pembrolizumab (Keytruda), nadofaragene firadenovec (Adstiladrin), nogapendekin alfa inbakicept (Anktiva), gemcitabine intravesical system (Inlexzo; formerly TAR-200), off-label gemcitabine/docetaxel, and clinical trials.

11. Does the guideline recommend a preferred sequence of BCG-unresponsive therapies?

No. Clark noted that comparative and sequencing data for these agents are lacking.

"We all know that comparing across trials is difficult and challenging. We all do it, but we all do it inappropriately," he said. "The panel very specifically declined to lay out an order of attack here, and so it really does fall on the individual practitioner to figure out."

Clark encouraged clinicians who do not manage NMIBC daily to consult colleagues, noting that practice-level logistics and staffing add complexity. The panel also developed new algorithms to help clinicians navigate the guideline.

12. What are the recommendations for enhanced cystoscopy and surveillance?

Clinicians should offer BLC at TURBT, if available, to increase detection and decrease recurrence (Moderate Recommendation; Evidence Level: Grade B), and may use narrow-band imaging for the same purpose (Conditional Recommendation; Evidence Level: Grade C). The first surveillance cystoscopy should occur within 3 to 4 months of initial treatment, with subsequent surveillance adjusted by risk (Expert Opinion).

For low-risk patients whose first surveillance cystoscopy is negative, surveillance cystoscopy should be performed 6 to 9 months later, then annually. After 5 years without recurrence, surveillance should be based on shared decision-making (Moderate Recommendation; Evidence Level: Grade C). In intermediate-risk patients, cystoscopy should be performed with cytology every 3 to 6 months for 2 years, then every 6 to 12 months for years 3 and 4, then annually (Expert Opinion). In high-risk patients, surveillance cystoscopy should be performed with cytology every 3 to 4 months for 2 years, then every 6 months for years 3 and 4, then annually (Expert Opinion).

Upper tract imaging should be performed in intermediate- and high-risk patients every 1 to 2 years (Expert Opinion).

13. What questions remain unanswered?

Clark identified the BCG-naïve high-risk setting as a major open question due to supply constraints and downstream effects. He pointed to the BRIDGE trial comparing gemcitabine/docetaxel with BCG for noninferiority in BCG-naïve disease as a study that may influence practice in this space.

He also cited ongoing work on biomarkers that could reduce or eliminate the need for cystoscopy.

Clinicians should also expect the guideline to keep evolving. As Clark put it, "don't be surprised if another iteration of an update happens in another 1.5 years, because the AUA is committed to reviewing these on a regular basis, and the field is changing so rapidly."

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REFERENCES
1. Clark PE, Holzbeierlein J, Chang SS, et al. 2026 Updates to the Diagnosis and Treatment of Non-muscle Invasive Bladder Cancer: AUA/SUO Guideline. J Urol. September 3, 2026. doi:10.1097/JU.0000000000005280

2. American Urological Association Releases Non-Muscle Invasive Bladder Cancer Guideline Amendment. News release. September 3, 2026. Accessed October 5, 2026. https://www.auanet.org/about-us/media-center/aua-press-center/american-urological-association-releases-non-muscle-invasive-bladder-cancer-guideline-amendment