Q&A: Suzanne B. Merrill, MD, FACS, on perioperative therapy in MIBC

Perioperative systemic therapy has reshaped how muscle-invasive bladder cancer (MIBC) is managed. Enfortumab vedotin-ejfv (EV; Padcev) plus pembrolizumab (Keytruda) has seen rapid uptake in this setting. VOLGA trial (NCT04960709) results presented at the 2026 European Society for Medical Oncology Congress now raise new questions about which regimen fits which patient.

Suzanne B. Merrill, MD, FACS, a urologic oncologist at Colorado Urology, an affiliate of One Urology, spoke with Urology Times® at the 2026 LUGPA Annual Meeting about the changing perioperative approach. She discussed the move away from cisplatin eligibility, how VOLGA could affect regimen choice, and how she works with medical oncologists on regimen selection. She also covered ctDNA’s role in staging and whether some patients may still be best served by cystectomy alone.

This Urology Times Q&A has been edited and consolidated from a recorded interview to improve readability while preserving the substance of the original conversation.

Urology Times: How have new perioperative approaches changed management of MIBC?

Merrill: It’s completely turned it on its head. I would say we no longer have this definition, and we just talked about this today, of cisplatin eligibility. Really, [the] traditional statement has really gone by the wayside, and we should actually not even think about classifying patients as such, not even for studies even more.

And so it really has [seen] rapid uptake in patients who [have] muscle-invasive disease to undergo EV and P [enfortumab vedotin and pembrolizumab] in a perioperative regimen.

Urology Times: How could the VOLGA results affect perioperative regimen selection?

Merrill: Now, what I think is going to slightly upset this is the new VOLGA trial results [that] just came out at ESMO. When that gets FDA approved, I think [it] is going to cause a little bit of disruption as to: Should all patients just get EV and P, because they’re going to get that EV on the back end, the adjuvant setting? Or is the VOLGA regimen, with EV and durvalumab [Imfinzi] and [then] durvalumab in the adjuvant setting, [a] treatment de-intensification option [that] shows some pretty similar results, at least to the EV-303 [NCT03924895] data?

And again, [for] this old traditional classification of cisplatin-ineligible patients, could that be an option to consider? And ultimately, do we think, too, if that again gets FDA approved, [it] will also expand, as we don’t have this cisplatin criteria anymore, to be thought of for all muscle-invasive bladder cancer patients? Could that be an option? It’ll be an interesting time.

Urology Times: How do urologists and medical oncologists decide on a perioperative regimen together?

Merrill: I think [it’s] a very important discussion to have with your medical oncologist. A lot of us urologists are not administering EV right now, so we are sharing that space still, and rightfully so, with our medical oncologist, as to what perioperative regimen we’re going to put these patients on. And is there going to be more personalization as to who we put [on which regimen]?

So do we need a more treatment-intensified regimen for patients, for example, [who] start out, if we have this information up front, showing by staging imaging T3 and higher [and] ctDNA positive? Maybe they need the more treatment-intensified regimen of EV and P perioperatively. If [it’s] more localized disease, maybe not such a treatment intensification, and using the VOLGA [regimen], EV and durvalumab and then durvalumab in the adjuvant setting. So we’ll see if that takes on a life of its own in helping us to select which perioperative regimen based on their disease status, maybe.

Urology Times: How could ctDNA testing help guide treatment intensity in bladder cancer?

Merrill: [With] minimal residual disease, ctDNA [circulating tumor DNA], I think there’s probably more to come on that element, as mostly what we use is called whole exome sequencing, but a lot of new tests are coming to market looking at whole genome sequencing. In that space right now, there’s not a lot of clinical validation in urothelial cancer. But again, statistically, whole genome sequencing could be more sensitive, reducing our false negatives for ctDNA in patients.

The ctDNA piece is helpful, again, in that prognostication. Do we truly understand their current stage of disease? ctDNA negative, hopefully they don’t have any other disease outside their bladder. Again, ctDNA positive should shed light on [whether] maybe we’re not really truly appreciating the current staging we understand.

And hopefully in the future we’ll be having utDNA [urine tumor DNA], which will really help out our non–muscle-invasive bladder cancer side of things, but very nicely complement the muscle-invasive bladder cancer side too, [in] fully understanding the patient’s whole-body disease stage.

Urology Times: Is there anything else you’d like our audience to take away?

Merrill: I probably would add just an element of: We’ve really moved out of this current thinking of performing an up-front cystectomy, with a lot of these perioperative regimens looking at cystectomy only vs the perioperative regimen and cystectomy. And of course, all those trials have read out in favor of the perioperative regimen [and] cystectomy.

So is there a patient-specific criteria where we would want to preserve these very powerful systemic agents to later on in their disease? And this applies [to NMIBC] as well, POTOMAC [NCT03528694] and BCG and durvalumab, using it [in the] BCG-naive [setting]. Are we using some of these very powerful systemic agents too early in the disease?

What I think is going to help us understand [is]: Is there a patient population, going back to muscle-invasive disease, [in which] we don’t want to use any of these agents just yet? Are they the perfect, again, isolated storm, I’ll call it, where [it’s] small volume, completely T2, ctDNA negative, even pulling out [a] Decipher genomic class[ifier result of] luminal, for example, [a] less aggressive form? You could even [have them] MRI [and] PET scan negative. As best you can understand, are they truly just T2? Maybe that’s a patient [who] would be just fine with cystectomy alone, allowing them to avoid toxicity with these systemic regimens [and] allowing them to use these systemic regimens down the line if they need to.

Because we’re positioning ourselves in a place, with using these regimens up front, [where] if they do progress, what do we have available? What do our medical oncologists have available? So I think it’s something to think about: Can our diagnostics be good enough to identify such patients [so] we could reserve some of these systemic agents for later?