Early Recurrent Low-Grade, Intermediate-Risk NMIBC

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The final segment presents the challenging case of a 68-year-old male Army veteran on an anticoagulant for atrial fibrillation who develops recurrent low-grade bladder cancer. This case highlights the additional complexity of treating patients with comorbidities that increase surgical risk, including the need to hold anticoagulants for procedures and the increased bleeding risk associated with repeated TURBTs. The discussion addresses the potential connection between Agent Orange exposure and bladder cancer development in veterans, adding another layer of complexity to risk assessment. The panel emphasizes how repeated surgical interventions in patients on anticoagulants resulting in procedural risks and health care costs.

The case progression demonstrates the futility of continued surgical management when patients experience multiple early recurrences, with this patient requiring 4 TURBTs within 18 months. The panel discusses the Einstein definition of insanity—continuing the same approach while expecting different results—and emphasizes the need to recognize treatment failure patterns early. The panelists highlight how repeated procedures increase complication rates, including perforation risk, readmission rates, and major complications. The discussion stresses the importance of shared decision-making and early introduction of alternative treatment strategies before patients become trapped on the TURBT treadmill.

The segment concludes with an optimistic outlook on the expanding therapeutic landscape for intermediate-risk non-muscle invasive bladder cancer (NMIBC), with multiple clinical trials ongoing beyond UGN-102. The panel discusses how this represents a true paradigm shift in bladder cancer management, moving from a purely surgical approach to incorporating effective medical therapies. The panelists emphasize that while surgeons are trained to perform TURBTs, recognizing when surgery is not the optimal solution is equally important. The discussion highlights the potential for these advances to significantly improve patient quality of life, reduce health care costs, and provide more personalized treatment approaches for the large population of patients with intermediate-risk NMIBC who have been historically underserved by available treatment options.