The UroOnc Minute: Key Updates to the AUA NMIBC Guideline, With Peter E. Clark, MD

Welcome back to The UroOnc Minute!

In this episode of The UroOnc Minute, host Adam B. Weiner, MD, is joined by Peter E. Clark, MD, chair of urology at Atrium Health and professor of urology at Wake Forest University in Charlotte, North Carolina, to discuss key updates from the American Urological Association’s recent amendment to its guideline on non–muscle invasive bladder cancer (NMIBC).¹ Clark, who served as the guideline chair, highlights several changes that may have important implications for clinical practice, including revisions to risk stratification, the evolving role of biomarkers, and greater attention to variant histologies.

One notable change is the classification of high-grade Ta disease, which is now considered high risk regardless of tumor size. Clark also discusses the growing use of biomarkers as prognostic tools and in the evaluation of uncertain cytology, as well as their potential role in reducing the frequency of cystoscopy in select patients. The conversation also addresses variant histologies, which may prompt clinicians to consider earlier radical cystectomy given limited evidence regarding their response to intravesical therapy and their association with adverse outcomes.

For patients with BCG-unresponsive disease, Clark describes an increasingly complex treatment landscape that includes systemic and intravesical therapies, off-label regimens, and clinical trials. However, he emphasizes that the available treatments have not been adequately compared with one another, leaving clinicians without a clear evidence-based sequence for selecting among these options. The discussion also explores findings from the CISTO trial (NCT03933826) regarding quality of life after cystectomy vs alternative intravesical therapies, underscoring the importance of providing patients with a nuanced discussion of bladder preservation and cystectomy.

In the intermediate-risk setting, Clark highlights the addition of UGN-102 as another option for recurrent low-grade Ta disease, alongside efforts to reduce the morbidity associated with repeated procedures through approaches such as in-office fulguration and surveillance in selected patients.

The experts also look ahead to unanswered questions in NMIBC, including treatment strategies for BCG-naïve high-risk disease, the potential role of gemcitabine and docetaxel as an alternative to BCG, emerging biomarkers, and novel therapeutic approaches. With the NMIBC treatment landscape continuing to evolve rapidly, Clark closes by emphasizing the importance of staying current with guideline updates and seeking input from colleagues when navigating increasingly complex treatment decisions.

REFERENCE

1. Clark PE, Holzbeierlein J, Chang SS, et al. 2026 Updates to the Diagnosis and Treatment of Non-muscle Invasive Bladder Cancer: AUA/SUO Guideline. J Urol. Published online September 3, 2026. doi:10.1097/JU.0000000000005280