Summary

Brant A. Inman, MD, MS, FRCSC, Chin-Hardie Chair of Urologic Oncology and Professor of Urology and Oncology, Western University, London, Canada, reviews the rapidly expanding treatment landscape for patients with non–muscle invasive bladder cancer whose disease does not respond to bacillus Calmette-Guérin (BCG). Dr. Inman focuses on therapies beyond BCG, such as intravesical agents, immunotherapies, and new technologies, emphasizing data from recent randomized trials attempting to improve outcomes while preserving the bladder.

Dr. Inman discusses intravesical chemotherapy strategies, including convective hyperthermia and radiofrequency-induced thermochemotherapy. Trials using heated mitomycin C demonstrate mixed results, with efficacy appearing dependent on disease phenotype, particularly poorer outcomes in carcinoma in situ compared with papillary disease. These findings underscore the importance of tumor biology when selecting salvage approaches.

Dr. Inman then describes the TAR-200 intravesical drug delivery system, an osmotic pump that provides sustained gemcitabine exposure. Data from the SunRISe-1 trial show high initial complete response rates with manageable toxicity, leading to regulatory approval and further combination studies.

The presentation transitions to immunotherapy approaches, outlining checkpoint inhibitors, cytokine-based therapies, and viral gene therapies. Single-arm studies of systemic checkpoint inhibitors demonstrate modest durability, while combination strategies pairing BCG with checkpoint blockade show improved event-free survival in large randomized trials. However, benefits are modest and accompanied by higher rates of immune-related adverse events. Differences among the CREST, POTOMAC, and ALBAN trials are examined, highlighting how trial design, maintenance schedules, and recurrence definitions influence outcomes.

Additional FDA-approved options are reviewed, including nadofaragene firadenovec and nogapendekin alfa inbakicept, as well as emerging viral therapies such as cretostimogene. Dr. Inman concludes that multiple effective options now exist for BCG-unresponsive disease, but optimal sequencing, comparative effectiveness, toxicity management, and cost remain unresolved challenges requiring future randomized studies.

About The 12th Urology Today Conference:

Presented by chair Ryan P. Terlecki, MD, FACS, the 12th Urology Today conference was designed to keep urologists, urologic oncologists, and other healthcare providers educated on the most pertinent issues in urology practices. Areas of focus included urologic oncology, men’s health and reconstruction, female urology, pediatric urology, kidney stones and related conditions, and methods of providing the best care amidst the required logistics of the business side of medicine.

ABOUT THE AUTHOR

Brant A. Inman, MD, MS, FRCSC

Chin-Hardie Chair of Urologic Oncology, Professor of Urology and Oncology at Western University | + posts

Brant A. Inman, MD, MS, FRCSC, is Chin-Hardie Chair of Urologic Oncology and Professor of Urology and Oncology at Western University in London, Canada. Dr. Inman’s clinical specialties include cancers of the prostate, bladder, kidney, ureter and renal pelvis, testis, adrenal, penis, and sarcomas. He has a particular interest in inherited genetic syndromes that cause urological cancers and in complex cancers that require multi-disciplinary care. Dr. Inman performs surgery using a wide variety of methods including laparoscopic and robotic minimally invasive surgery, endoscopic surgery, and open surgery.

Dr. Inman earned his Bachelor of Medical Science and MD from the University of Alberta in Edmonton, Canada. He then completed a residency in Urology at l’Université Laval in Québec City, Canada. Dr. Inman subsequently completed a fellowship in Urologic Oncology and earned his Master’s in Clinical and Translational Research at the Mayo Clinic in Rochester, Minnesota.

Dr. Inman has served as a researcher for several projects including the development of new diagnostic tests for cancer, the development and testing of new treatments for cancer, understanding the immune response to cancer, and describing the genetic underpinnings of cancer. His research interests are in the field of urologic oncology, including clinical trials and translational research related to bladder, prostate, and kidney cancer. Dr. Inman has authored and co-authored over 240 publications in his field. He has been a member of Board of Directors of the Society of Urologic Oncology Clinical Trials Consortium, a member of the National Comprehensive Cancer Network bladder and penile cancer panel, a member of the Research Council and Research Grants and Investigator Support Committee of the American Urological Association, and a member of the Urological Research Society.