The UroOnc Minute: Managing Intravesical Therapy Toxicity in NMIBC, With Vignesh Packiam, MD

Welcome back to The UroOnc Minute!

In this episode of The UroOnc Minute, host Adam B. Weiner, MD, sits down with Vignesh T. Packiam, MD, associate professor of surgery at Rutgers Robert Wood Johnson Medical School, to discuss strategies for managing adverse effects associated with intravesical therapy for non–muscle-invasive bladder cancer (NMIBC). As treatment options expand beyond BCG to include additional FDA-approved therapies and intravesical chemotherapy combinations, maintaining treatment tolerability and preserving bladder function have become increasingly important considerations.

Packiam discusses the cumulative toxicity that can develop with prolonged intravesical treatment, including chronic chemical cystitis, bladder spasms, and difficulty retaining medication. He outlines several approaches to improving tolerability, including anticholinergic medications, selective use of β3-adrenergic agonists, urinary alkalinization with sodium bicarbonate, and medications to address anxiety and pain during treatment. Packiam also describes gravity instillation, a technique in which the catheter is connected to Foley tubing and an elevated drainage bag, allowing medication to reflux into the tubing during bladder spasms and return to the bladder as the spasms subside. He explains how his team at Rutgers has incorporated this technique into clinical practice for patients receiving gemcitabine and docetaxel, as well as selected patients receiving BCG and other intravesical therapies.

The discussion also highlights the need for more proactive, standardized approaches to managing treatment-related symptoms. Packiam describes emerging research into interventions such as acupuncture, neuromodulation, and other approaches to preserving bladder capacity and function during repeated intravesical treatment. He also reflects on findings from the CISTO trial, which compared cystectomy with additional intravesical therapy in patients with recurrent NMIBC after BCG and found better patient-reported quality of life among those who underwent cystectomy.¹ According to Packiam, the findings underscore the importance of balancing bladder preservation with patients’ quality of life and identifying ways to improve the experience of those who continue intravesical treatment. Packiam discusses how structured treatment pathways and greater involvement from advanced practice providers can help clinicians escalate supportive interventions as tolerability issues arise, with the goal of helping patients continue therapy while preserving bladder function.

REFERENCE

1. Gore JL, Wolff EM, Nash MG, et al. Twelve-Month Results From the CISTO Study Comparing Radical Cystectomy Versus Bladder-Sparing Therapy for Recurrent High-Grade Non-Muscle-Invasive Bladder Cancer. J Clin Oncol. 2026;44(4):274-285. doi:10.1200/JCO-25-01324