Intravesical therapy (BCG and bladder instillations)
Putting a drug directly into the bladder through a catheter and leaving it for an hour or two, so it treats the lining without going round the body. BCG, a weakened tuberculosis vaccine, has been the most effective such drug for 45 years.
A single instillation of mitomycin or gemcitabine after TURBT reduces recurrence of low-risk tumours; six weekly BCG instillations plus maintenance for 1-3 years (SWOG schedule) is standard for intermediate- and high-risk NMIBC and carcinoma in situ, provoking a local immune response. BCG shortages have forced reduced-dose and alternative schedules. For BCG-unresponsive disease, intravesical nadofaragene firadenovec (gene therapy), cretostimogene (oncolytic virus), the TAR-200 gemcitabine-releasing device and systemic pembrolizumab now compete with cystectomy; adding durvalumab to BCG (POTOMAC, 2026) extended disease-free survival in high-risk disease. Chemohyperthermia and electromotive delivery are other enhancements.
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