Reducing repeat procedures in low-grade, intermediate-risk NMIBC

The management of recurrent low-grade and intermediate-risk non–muscle invasive bladder cancer (NMIBC) is evolving rapidly, with emerging therapies such as mitomycin for intravesical solution (Zusduri) beginning to challenge traditional approaches like transurethral resection of bladder tumor (TURBT) and active surveillance. Although historically, the standard management for these patients has relied on periodic TURBTs and cystoscopic surveillance, mitomycin for intravesical solution offers the potential for less invasive treatment while targeting tumors in situ. At a recent Urology Times Clinical Forum in Phoenix, Arizona, urologists illuminated the factors shaping its adoption, patient preferences, and the practical realities of integrating this therapy into clinical practice. The forum was hosted by Mark D. Tyson II, MD, MPH, of Mayo Clinic in Phoenix, Arizona.

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

Active surveillance's role

One striking theme from these discussions was the continued centrality of active surveillance. Many patients with small, low-grade papillary tumors prefer monitoring over intervention. One urologist reflected on his active surveillance cohort, noting that even after being informed about mitomycin for intravesical solution in clinical trials, the vast majority of patients declined treatment. “Almost all of my active surveillance patients said ‘no’ when I offered ablation for stable, small papillary tumors,” he said. This hesitancy is often rooted not in a lack of trust in novel therapies, but in a preference to avoid procedures unless absolutely necessary. Patients often weigh the discomfort and uncertainty of interventions against the stability of their disease, with many opting for a “watch-and-wait” approach.

Cost and access are significant factors, though their impact differs across practice settings. Within the VA system, clinicians benefit from relatively flexible formularies, particularly amid shortages of traditional agents such as BCG. One VA clinician noted that pharmacies are increasingly supportive of alternative therapies during shortages, and that access to agents like nogapendekin alfa inbakicept-pmln (Anktiva) and nadofaragene firadenovec (Adstiladrin) is generally feasible for veterans, who often have multiple comorbidities and higher-risk disease. By contrast, in private or academic settings, institutional reimbursement structures and departmental budgets play a more substantial role in determining whether a therapy is offered. Several clinicians highlighted that although patient-level costs may be prohibitive in some settings, positive departmental margins can incentivize adoption, whereas loss-making drugs can effectively block usage regardless of clinical potential.

Administering treatments

Operational considerations are another critical aspect of mitomycin for intravesical solution implementation. Unlike agents such as nadofaragene, which can induce significant bladder spasms and lead to substantial drug loss if administered in the clinic, mitomycin for intravesical solution tends to be better tolerated. This allows some clinicians to administer the drug in an outpatient cystoscopy suite, rather than the operating room, which can help preserve precious OR time. However, in institutions where cost absorption strategies are important, some instillations of other novel therapies are still performed in the OR so the hospital, rather than the clinic, bears the cost. One academic urologist recounted that at Northwestern University, nadofaragene instillations are performed in the OR primarily to reduce medication waste and shift costs to the hospital. In contrast, mitomycin for intravesical solution’s formulation and tolerability allow for more streamlined administration.

Discussion also focused on patient selection and clinical scenarios where mitomycin for intravesical solution might be particularly valuable. Although many low-grade tumors can be managed with simple fulguration or biopsy during routine cystoscopy, there are cases where these approaches are less effective. For instance, a few younger patients with recurrent disease, or those with anatomically difficult lesions that are hard to fully resect, might benefit from mitomycin for intravesical solution to avoid repeated TURBTs. One clinician shared that for certain patients where complete tumor resection is challenging, mitomycin for intravesical solution could reduce the need for repeated procedures while maintaining disease control. However, the same clinician emphasized that this is not a universal approach: routine, “garden variety” low-grade tumors still respond well to in-clinic interventions, and overuse of novel agents can drive unnecessary costs without clear clinical benefit.

Mechanism of action

Another important consideration is the biologic mechanism of action. Clinicians discussed the promise of emerging targeted therapies like TAR-210, which may allow for receptor-guided treatment in the future. From a purely biological standpoint, these therapies are attractive because they could enable highly personalized approaches, potentially improving efficacy while minimizing toxicity. Current discussions suggest that although mitomycin for intravesical solution provides a useful non-surgical option, the future of low-grade urothelial carcinoma treatment may increasingly involve biomarker-driven therapy.

Follow-up and surveillance remain critical when integrating novel therapies. For patients receiving mitomycin for intravesical solution, cystoscopy and cytology are typically performed every 3 months, with imaging such as CT urograms performed annually or biennially. This intensive schedule ensures patient safety, allows timely assessment of therapeutic response, and justifies the substantial cost of these interventions. Clinicians emphasized that this follow-up is especially important given that many patients are likely to experience multiple recurrences over their lifetime, underscoring the need for a strategic, long-term approach to disease management.

Cost and reimbursement dynamics also weigh heavily on decision-making. In private practice settings, a positive departmental margin can make the adoption of mitomycin for intravesical solution more appealing. One clinician noted that if the drug were “budget neutral” or generated even modest revenue—such as ASP plus 6%—it would be compelling to offer the therapy in the clinic. Conversely, if departmental finances would be negatively impacted, clinicians might hesitate, regardless of clinical benefit. This tension between financial sustainability and patient care illustrates a broader challenge in the adoption of new therapies in urology.

The patient experience

Patient experiences further inform adoption. Clinicians reported that patients generally appreciate non-surgical approaches, particularly those that allow them to avoid repeated procedures under anesthesia. One VA urologist highlighted that the gemcitabine/docetaxel protocol is especially burdensome for patients due to adverse events and procedural requirements, whereas mitomycin for intravesical solution offers a more tolerable alternative with fewer logistical hurdles. Such considerations—combining efficacy, safety, patient comfort, and institutional feasibility—will likely guide which patients are selected for mitomycin for intravesical solution treatment in practice.

Ultimately, mitomycin for intravesical solution represents a promising addition to the urologist’s toolkit for managing recurrent low-grade urothelial carcinoma. Yet its adoption is influenced by a combination of patient preferences, clinical feasibility, and financial considerations. Active surveillance continues to compete strongly with novel therapies, particularly for small, stable lesions. In select cases—such as recurrent tumors in younger patients, difficult-to-resect lesions, or situations where procedural burden must be minimized— mitomycin for intravesical solution offers a compelling alternative. Clinicians are encouraged to evaluate each patient individually, weighing disease characteristics, patient goals, operational logistics, and cost considerations to optimize outcomes.

As awareness of mitomycin for intravesical solution grows, and as more clinical experience accumulates, this therapy may become a central component of recurrent low-grade and intermediate-risk NMIBC management. The discussion among academic and VA clinicians suggests that although challenges remain, including cost and operational logistics, the combination of efficacy, tolerability, and outpatient feasibility positions mitomycin for intravesical solution as a significant advance in personalized, minimally invasive urologic care.