Chemoablation broadens treatment options in recurrent NMIBC

Last month, urologists gathered in New York, New York, for an in-depth roundtable discussion on the management of low-grade, intermediate-risk non–muscle-invasive bladder cancer (NMIBC). Moderated by Katie S. Murray, DO, MS, the session brought together urologic oncologists and advanced practice clinicians from academic and community settings to discuss evolving strategies for this common but challenging disease. Murray is a professor in the Department of Urology at the New York University Grossman School of Medicine and chief of the Urology Service at Bellevue Hospital Center in New York, New York.

The conversation covered real-world diagnostic dilemmas, practical treatment considerations, and the potential role of new intravesical and chemoablative therapies, with participants emphasizing how patient preferences and system-level factors continue to shape care.

This summary was generated by artificial intelligence and edited by humans for clarity.

Defining the intermediate-risk category

The discussion opened with how clinicians interpret intermediate risk in NMIBC—a category that can encompass multifocal low-grade Ta lesions, solitary tumors larger than 3 cm, or recurrent low-grade disease within 1 year. Although the American Urological Association and European Association of Urology guidelines offer definitions, panelists agreed that in practice, this population remains heterogeneous.

“The intermediate-risk group is really a mixed bag,” Murray said. “There’s no single algorithm that applies to every patient.”

Participants highlighted that, with the shift from the historical grade 1 to 3 system to today’s low- and high-grade classification, many grade 2 tumors have migrated into the high-grade category, creating further gray areas. The consensus: Most intermediate-risk cases merit active management but do not require high-grade intensity.

Diagnostic workup: From cytology to imaging

Typical workup for a new presentation of hematuria includes urine cytology and CT or MRI urography, followed by cystoscopy. Panelists generally perform cytology on every case, but they questioned how often the result truly changes management.

“If you have gross hematuria, you’re going to need to investigate anyway,” one participant said.

The group discussed the occasional challenge of positive cytology with no visible tumor. In these cases, repeat cystoscopy or blue-light cystoscopy may help identify subtle lesions. Although blue-light cystoscopy was seen as valuable for detection, physicians cited obstacles such as false positives, reimbursement hurdles, and equipment availability.

Bacillus Calmette-Guérin (BCG) limitations and the rise of chemotherapy

All panelists acknowledged the continuing BCG shortage, now approaching a decade in duration. Although BCG remains the standard for high-grade or carcinoma in situ disease, most urologists have transitioned to gemcitabine or mitomycin C for low-grade recurrences.

“I haven’t used BCG for low-grade tumors in years,” one urologist said. “Gemcitabine is easier on patients and easier to get.”

Murray noted that she reserves BCG for her highest-risk patients, adding, “BCG works, but we have to prioritize who receives it.”

Case study: Recurrent low-grade Ta

The first case involved a 63-year-old man with a 2-cm low-grade Ta tumor who underwent transurethral resection of the bladder tumor (TURBT) followed by a 6-week induction of intravesical gemcitabine. He remained disease free for 6 months but developed multifocal recurrence at 9 months.

In this scenario, most clinicians said they would perform another TURBT and administer a repeat course of gemcitabine or mitomycin. A few may consider BCG or chemoablation, depending on the recurrence pattern and patient preference.

Large or multifocal lesions were described as “the most annoying” type of recurrence—rarely dangerous but often burdensome for patients due to repeated procedures.

Mitomycin for intravesical solution (Zusduri): A new option for chemoablation

Murray introduced recently approved data for mitomycin for intravesical solution, cleared by the FDA in June 2025, for the primary nonsurgical treatment of low-grade, intermediate-risk NMIBC.

The pivotal ENVISION trial (NCT05243550) enrolled 240 patients (mean age, 68 years); 80% had multifocal disease, and 52% had recurred within a year of diagnosis. All received 6 weekly instillations of mitomycin for intravesical solution.

Key outcomes:

• 79% complete response at 3 months

• 78% durability of response at 12 months

• 3% progression to high-grade disease

• 14% grade 3 or higher adverse events, mostly mild urinary symptoms

Panelists viewed these findings as encouraging, particularly for patients reluctant to undergo another TURBT. “It’s something new to offer frustrated patients,” one participant said. “They’ve been on the ‘TURBT treadmill’ for years.”

Others emphasized the potential “field effect” of chemoablation: treating the entire bladder surface, including microscopic lesions not visible on cystoscopy.

Administration and practical barriers

Panelists who had already used mitomycin for intravesical solution described a straightforward administration process. The drug is shipped on ice as a liquid and gels at body temperature to achieve a dwell time of 5 to 24 hours. Catheters are typically left in place for approximately 15 minutes before removal.

“The patient can leave after 15 minutes, so it may actually open up chair time,” one participant said.

Challenges remain around reimbursement, cost, and workflow. Some academic centers require dual-provider verification for intravesical chemotherapy, which can slow throughput.

Nonetheless, clinicians agreed that once established, the procedure is manageable and potentially more efficient than repeat TURBTs.

Patient preferences and quality of life

Patients’ frustration with repeated cystoscopic procedures and anesthesia was a recurring theme. Many older adults experience postoperative retention or face social challenges, such as difficulties with transportation and caregiving needs.

Panelists said they increasingly frame mitomycin for intravesical solution as an option to “change the story” for these individuals. “When patients hear there’s something new that might spare them another surgery, they’re usually interested,” Murray said.

For patients who tolerate surgery well, traditional TURBT remains appropriate, underscoring the need for individualized, shared decision-making.

Case 2: A female smoker with recurrent disease

A 68-year-old woman with recurrent low-grade Ta disease and an active smoking history exemplified another common dilemma. Smoking was recognized as a clear recurrence risk factor warranting closer surveillance (every 3 months).

Given her history of frequent recurrences and reluctance for further surgery, participants agreed that chemoablation would be a reasonable alternative.

Surveillance and maintenance patterns

Follow-up schedules varied slightly among panelists but generally included 3-month cystoscopy after treatment, then 6-month intervals, eventually moving to annual exams if disease free. Some shorten intervals after initiating a new therapy to confirm durability.

Maintenance therapy remains individualized. Although most clinicians avoid long-term maintenance for low-grade disease, some use periodic gemcitabine instillations if early recurrences occur.

Case 3: Recurrence timing and clinical judgment

The final case, which included a patient on anticoagulation with recurrence 1 year after gemcitabine, prompted discussion about defining early vs late recurrence.

• Recurrence within 6 months: early failure → consider switching agent (eg, UGN-102)

• Recurrence at 12 months: acceptable durability → reinduction reasonable

Panelists agreed that management ultimately depends on clinical experience and patient context, not rigid timelines.

Beyond the clinic: Expanding access and education

The session concluded with a broader discussion of how to support community urologists as bladder cancer therapy rapidly evolves. Participants highlighted several needs, including the following:

• Improved education and training for office-based urologists

• Regional centers of excellence for new therapies and clinical trials

• Simplified decision tools and referral pathways

“Bladder cancer care is becoming much more complex,” one urologist said. “Not every practice can offer every new therapy. We need collaborative networks so patients everywhere have access.”

Conclusion

The forum underscored the rapidly changing treatment landscape for low-grade, intermediate-risk NMIBC.

Although gemcitabine remains a mainstay, the approval of mitomycin for intravesical solution provides a practical chemoablative alternative for patients with recurrent, multifocal disease, especially for those eager to avoid repeat surgery.

Panelists agreed that treatment success depends not only on efficacy but also on access, workflow, and patient experience. With multiple new agents in development and a growing focus on quality of life, urologists are entering a new era of personalized, guideline-informed care for NMIBC.