Editorial Comment
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Low-grade nonmuscle-invasive bladder cancer (NMIBC) commonly recurs but rarely progresses to more invasive disease.1 For intermediate-risk NMIBC, guideline-concordant care consists of transurethral resection of the bladder tumor (TURBT) and consideration of perioperative intravesical chemotherapy. Although TURBT remains a routine outpatient procedure for urologists, significant perioperative risks exist for a patient population that is commonly advanced in age with multiple comorbid conditions.2 Evaluations of tumor chemoablation that avoids these operative risks date back to the 1980s. The ENVISION trial continues these efforts using a reverse thermal hydrogel formulation of mitomycin (UGN-102)1 and complements previously reported results from the Optima II and ATLAS trials.
Unfortunately, the single-arm trial design limits our knowledge of how these results compare with other management strategies. For example, in the DaBlaCa-13 study, which evaluated intensive chemoresection with mitomycin C (40 mg/mL 3 times per week for 2 weeks) among patients with recurrent NMIBC (either low or high grade), the need for procedural intervention was significantly reduced compared with those who received guideline-concordant care.3 How UGN-102 compares with TURBT followed by intravesical treatments remains a mystery as neither the ENVISION nor ATLAS trial included a comparator arm that allowed for these standard-of-care options. However, if the goal is to maximize quality of life and reduce cost without compromising oncologic outcomes, perhaps a fairer comparator would be active surveillance, a strategy that similarly avoids surgery and appears to be safe for well-selected patients.4
In the absence of head-to-head comparisons, it is reasonable to conclude that UGN-102 shows promise for patients unfit for surgical resection. Future work is needed to understand the functional and financial toxicity tradeoffs between available management options for recurrent low-grade NMIBC to help guide preference-sensitive care.
REFERENCES
- 1. . Primary chemoablation of recurrent low-grade intermediate-risk nonmuscle-invasive bladder cancer with UGN-102: a single-arm, open-label, phase 3 trial (ENVISION). J Urol. 2025; 213(2):205-216. doi: 10.1097/JU.0000000000004296 Link, Google Scholar
- 2. . Short term complications from transurethral resection of bladder tumor. Can J Urol. 2016; 23(2):8198-8203. Medline, Google Scholar
- 3. . DaBlaCa-13 study: oncological outcome of short-term, intensive chemoresection with mitomycin in nonmuscle invasive bladder cancer: primary outcome of a randomized controlled trial. J Clin Oncol. 2023; 41(2):206–211. doi: 10.1200/JCO.22.00470 Crossref, Medline, Google Scholar
- 4. . Active surveillance in non-muscle invasive bladder cancer, the potential role of biomarkers: a systematic review. Curr Oncol. 2024; 31(4):2201-2220. doi: 10.3390/curroncol31040163 Crossref, Medline, Google Scholar
