Balancing Bladder Preservation and Oncologic Risk in NMIBC

The expert faculty discuss how to approach management for patients who experience NMIBC recurrence after receiving combination BCG and checkpoint inhibitor therapy. They explore how to individualize decisions based on disease characteristics, treatment interval, and patient preference—especially for those reluctant to undergo radical cystectomy despite guideline recommendations. Faculty note that patients with recurrent high-grade T1 disease generally remain at significant risk for progression and may still benefit most from cystectomy, while those with high-grade Ta or CIS can often be safely managed with novel intravesical therapies such as N-803 or nadofaragene firadenovec. The panel emphasizes the evolving treatment landscape, with multiple promising phase 3 trials—CREST, POTOMAC, and upcoming studies like PATAPSCO—offering evidence for immunotherapy combinations that may further delay or reduce the need for cystectomy. They agree that the ultimate goal is preserving quality of life while optimizing long-term disease control through thoughtful patient selection.