How to cite: Bochner BH, Petrylak, DP, Dreicer, R, et al. “Session 4 Panel Discussion: Radical Surgical Approaches to Bladder Cancer.” December 2025. Accessed Oct 2026. https://grandroundsinurology.com/session-4-panel-discussion-radical-surgical-approaches-to-bladder-cancer/

Summary

This expert panel explores controversial and rapidly evolving questions across non–muscle-invasive and muscle-invasive urothelial cancer, including trial design, immune therapy toxicity, ctDNA-guided (circulating tumor DNA) management, perioperative sequencing, radiation integration, and mechanisms of resistance to antibody-drug conjugates.

The discussion begins with intermediate-risk non–muscle-invasive bladder cancer and whether surveillance is an appropriate control arm in phase III trials. Panelists emphasize the heterogeneity of the intermediate-risk category and note that many patients in real-world practice undergo observation alone. Regulatory requirements now mandate randomized trials rather than single-arm chemoablation studies, with observation accepted as a control in settings lacking a universally applied standard of care.

Debate then shifts to immune checkpoint combinations in non–muscle-invasive disease. Panelists express concern that modest reductions in high-grade non-progressive recurrences do not justify systemic immune toxicity, particularly given the continued effectiveness of Bacillus Calmette-Guérin (BCG) in appropriately selected patients. The need to avoid overtreatment of the majority who respond to BCG is emphasized.

In muscle-invasive disease, ctDNA-guided adjuvant therapy generates substantial discussion. Questions include whether to escalate therapy based on positive ctDNA in the absence of radiographic disease, the binary versus quantitative interpretation of ctDNA results, and the uncertainty regarding lead time and false negatives. Clinical judgment remains central.

The panel also addresses mechanisms of resistance to enfortumab vedotin and antibody-drug conjugates, including payload resistance, linker technology, and human epidermal growth factor receptor 2 expression thresholds. Dual-payload antibody-drug conjugates and improved biomarker selection are highlighted as future directions.

Challenges in integrating Fibroblast Growth Factor Receptor inhibitors, targeted therapies, and radiation strategies are discussed, particularly the logistical barriers to molecular testing and treatment selection in acutely ill patients.

The session underscores the tension between innovation, toxicity, biomarker uncertainty, and the need for better patient selection.

How to cite: Bochner BH. Surgical Quality, Urinary Diversion, and QOL Considerations for Invasive Bladder Cancer. December 2025. Accessed Oct 2026. https://grandroundsinurology.com/surgical-quality-urinary-diversion-and-qol-considerations-for-invasive-bladder-cancer/

Summary

Bernard H. Bochner, MD, FACS, Sir Murray F. Brennan Chair in Surgery, and Professor in the Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York, examines contemporary data on surgical quality, complications, urinary diversion, and patient-reported quality of life after radical cystectomy.

Radical cystectomy principles include wide excision of the bladder and perivesical tissues with regional lymph node dissection. In a series of more than 2,200 cystectomies, approximately 300 local recurrences were observed. Detailed mapping showed that many recurrences occurred in residual nodal packets, underscoring the importance of thorough lymph node dissection.

Surgery alone cures the majority of patients with organ-confined disease and more than 60 percent of patients with extravesical, node-negative disease. Even among node-positive patients, approximately one-third remain disease-free without adjuvant therapy. Increased use of neoadjuvant platinum-based chemotherapy and improved lymph node yields have contributed to these gains.

Perioperative morbidity remains significant, with approximately two-thirds of patients experiencing a complication within 90 days. Most complications are grade 1 or 2.

Contrary to common perception, patient-reported global quality of life does not demonstrate a dramatic or sustained decline after cystectomy. Recovery to baseline occurs by 12 months and is maintained for two years. Even patients aged 80 years and older do not experience significant deterioration in global quality of life, though physical functioning declines transiently. Recurrence has a substantial negative impact on quality of life.

Sexual function and body image represent domains with persistent impact, particularly in younger patients and those undergoing ileal conduit diversion. Despite the availability of continent reconstruction, rates remain below 10 percent in the United States.

Dr. Bochner stresses that surgical quality matters and sets a high standard for oncologic and functional outcomes in bladder-sparing strategies.

How to cite: Bochner BH. Session 1 Panel Discussion: Pathology, Etiology, and Diagnosis of Urothelial Cancer. Grand Rounds in Urology. December 2025. Accessed Oct 2026. https://grandroundsinurology.com/session-1-panel-discussion-pathology-etiology-and-diagnosis-of-urothelial-cancer/

Summary

A multidisciplinary panel examines the practical implementation of enhanced cystoscopy, the evolving management of carcinoma in situ, and the potential role of artificial intelligence in improving diagnostic precision and clinical trial interpretation.

The panel focuses on real-world adoption of blue light cystoscopy and narrow band imaging in the surveillance and management of non–muscle-invasive bladder cancer. Participants describe variability in practice patterns driven by workflow constraints, cost, equipment availability, and scope platform limitations. Blue light cystoscopy requires pre-procedure intravesical instillation and scheduling adjustments, limiting spontaneous use in busy clinics. Narrow band imaging is easier to toggle during standard cystoscopy, but it is not universally available, particularly as disposable scopes become more common.

Operational challenges, maintenance contracts, and discontinuation of certain flexible blue light platforms further restrict access. Despite these barriers, participants emphasize that enhanced imaging technologies improve visualization of small papillary tumors and carcinoma in situ. The debate centers on whether enhanced cystoscopy should be mandated in clinical trials to standardize detection and reduce variability in the quality of transurethral resection of bladder tumors.

A major theme involves carcinoma in situ heterogeneity. Small focal lesions detected with enhanced imaging may biologically differ from extensive multifocal disease, yet both are categorized similarly in single-arm trials. The panel questions assumptions that all carcinoma in situ represents persistent disease after resection, noting that aggressive resection and fulguration may eliminate visible disease in a subset of patients. Lack of objective quantification methods complicates the assessment of response and the interpretation of therapeutic efficacy.

Participants discuss limitations in histologic sampling of carcinoma in situ and challenges in molecular analysis due to minimal tissue volume. Urinary-based assays and circulating tumor DNA are suggested as potential objective tools. Artificial intelligence–based cystoscopic enhancement, image capture, and three-dimensional mapping may enable quantification of lesion surface area and improve longitudinal assessment of response.

The discussion highlights the need for standardization, objective measurement, and integration of emerging technologies in both clinical practice and trial design.

Bernard H. Bochner, MD, FACS, presented “Role of PLND for High Risk Bladder Cancer” at the 7th International Bladder Cancer Update on December 6, 2024, in Dallas, Texas.

How to cite: Bochner, Bernard H. “Role of PLND for High Risk Bladder Cancer” December 2024. Accessed Oct 2026. https://grandroundsinurology.com/role-of-plnd-for-high-risk-bladder-cancer/

Role of PLND for High Risk Bladder Cancer – Summary

Bernard H. Bochner, MD, FACS, examines the extent of lymph node dissection in bladder cancer surgery and its impact on oncologic outcomes. In this 14-minute presentation, he addresses pelvic lymph node involvement in invasive bladder cancer; historical data suggest that about one-third of patients with node-positive disease achieve long-term survival following surgery alone. 

Dr. Bochner debates whether extending the lymph node dissection above the common iliac bifurcation to the aortic bifurcation improves outcomes. A German trial demonstrated a 5% improvement in recurrence-free survival with extended dissection. However, the SWOG S1011 trial excluded patients with radiographically evident N3 disease and found no benefit. Morbidity rates varied, with the German study showing no increased complications, whereas SWOG reported a significant rise in major surgical toxicities. The findings suggest that extended lymph node dissection may benefit high-risk patients but remains controversial due to study limitations and selection biases. 

Dr. Bochner believes that standardization of surgical approaches and further trials are needed to clarify the role of extended lymphadenectomy in bladder cancer management.

About the 7th International Bladder Cancer Update:

The International Bladder Cancer Update (IBCU) is a CME conference focused on the diagnosis and treatment of bladder cancer. The conference offers medical professionals an opportunity to listen to updates from, and interact with, expert international faculty to improve knowledge and determine best treatment practices to improve patient outcomes. IBCU encompasses expert lectures, interactive discussions, a panel roundtable, debates, and case presentations. It is physician-led, multi-supported, and designed for urologists, urologic oncologists, and other healthcare professionals involved in the treatment of bladder cancer.

For further educational activities from this conference, visit our collection page.