Therapeutic Advances in Bladder Preservation for BCG-Unresponsive Non-Muscle Invasive Bladder Cancer

Bacillus Calmette-Guérin (BCG) has long been the standard treatment for preventing recurrence and progression following resection of high-risk non-muscle invasive bladder cancer (NMIBC). Unfortunately, recurrence or progression despite BCG induction and maintenance treatment have significant prevalence-a persistent issue in urologic oncology. Notable advancements in the development of alternative therapeutic options have become available and are in the pipeline. This review aims to provide an overview of the current treatment landscape for patients with BCG-unresponsive NMIBC, highlighting both existing and emerging therapies that are expected to become more widely available. A narrative review based on data collected through the end of 2024. Several treatment options, aside from radical cystectomy (RC), are currently available or in promising stages of clinical trials. Many of these treatment modalities were granted Fast Track and Breakthrough Therapy status due to their initial success. These include novel chemotherapy regimens, immune checkpoint inhibitors, device-assisted therapies, and new intravesical and systemic agents. Combination therapies combining traditional treatments and newer approaches were explored. The next few years promise to offer patients a variety of new, effective therapies for BCG-unresponsive NMIBC. These advancements hold significant potential for improving patient outcomes and providing more targeted, organ-sparing treatment options.