Q: Is the avoidance of intravesical chemo when concern for bladder perforation applicable to ALL suspected perforations, or only intraperitoneal perforation? Thank you. 

A: ALL – even suspected. Have a low threshold to avoid

Q: Do you routinely take prostatic urethral biopsies if positive cytology with normal cystoscopy (when doing bladder biopsies in OR)?

A: YES

Q: A few people have written into the chat.. should cold cup biopsies be taken on reTUR? What to do if no visible disease on reTUR? random biopsy vs biopsy of old resection site vs no biopsies. TY

A: Always take something at old resection site. Re-TUR vs. deep cold cup biopsy. resect entire site

Q: What was the reason for downgrading TaHG tumors from high risk to intermediate risk?

A:Great question. Much debated. A small, solitary HGTa tumor has a lower risk profile for recurrence and progression than a larger, recurrent tumor – therefore in intermediate.

Q: Also, for intermediate risk chemo or bcg can be used. Is the AUA’s stance now that TaHG is more reasonable to use chemo instead of BCG for treatment?

A:AUA/SUO guidelines recommend chemo or BCG for intermediate-risk and BCG for high-risk. Depends which category TaHG falls.

Q: When you all see a patient with recurrent LG Ta disease with recurrences on office cystoscopy and you decide the patient would benefit from office fulguration, do you utilize intravesical gemcitabine in the office?

A:No, but great thought. You should consider a trial.

Q: What is the rationale for cyto in intermediate risk LG? Just to ensure you are not missing progression to HG or CIS?

A: Yes.

Q: Our guidelines say enhanced cystoscopy (HAL, NBI) should be offered if available at time of TURBT. Are you currently offering this and do you have any idea what proportion of centers do offer this? I ask because I know we currently do not have the ability.

A: We do have and offer. No idea how many centers have. Not critical – studies show decreases # recurrences and increases time to recurrence, but has not yet been shown to change cystectomy rates or survival,

Q: Can you review the definition of BCG unresponsive one more time please? I've seen some information on continuing with the first maintenance dose prior to calling it unresponsive -- how do you decide that versus repeat induction?

A: See guidelines 23-26. Briefly – Ta/CIS = fail BCG X 2 induction (or 1+maintenance); T1 = fail BCG X 1 induction

Q: any role for maintenance gemcitabine for intermediate risk or perhaps high risk?

A: Yes – for intermediate risk patients who respond to intravesical gemcitabine, can use as maintenance. For high-risk, they shoud be treated with induction BCG.

Q: Can you comment on NAC for variant pathology?

A: Depends on type of variant. There is increasing evidence that NAC is effective for some variants – e.g. neuroendocrine, some micropapillary. But, it is often important to evaluate the extent (percentage) of variant involvement. Patients with UC and some glandular elements or some squamous elements do well -- as good if not better than better than pure UC. But, pure adenocarcinomas or pure squamous cell carcimonas should go right to cystectomy.

Q: Regarding the question of the HGTa recurrence after BCG, why not re-resect that patient before repeat iBCG to ensure no progression?

A: Good catch. YES –that is the more accurate answer – to re-TUR then BCG.

Q: Can a reTUR be skipped in appropriately selected patients with high-risk disease? Some data from Europe supporting this, but not great level of evidence

A: I do not recommend skipping re-TURBT

Q: What are the current thinking of using single dose chemotherapy after TURBT when enhanced cystoscopy can be used?

A: I don’t think that use of peri-op chemo and enhanced cystoscopy are substitutes or replacements. Both can be used in a complementary fashion.

Q: We were told by our pulmonologist today that we should delay treatment of COVID-19 positive patients for 4 weeks. Particularly, we have a patient with very aggressive appearing UTUC with nodal enlargement. How would you consider weighing out the risks and benefits of delaying treatment and initiating NAC considering it will render the patient immunocompromised

A: Unfortunate dilemma. Nice try trying to sneak in a non-NMIBC question ;)

Q: Is there any data to show that 3 years of BCG maintenance is oncologically superior to 1 year?

A: See Oddens et al Eur Urol (2013) – evidence-based info on dosing and duration of maintenance. Especially relevant in times of BCG shortages.

Q: how do you handle a lower risk (ie small LG Ta) recurrence in the setting of a patient with hx high risk NMIBC on the high risk surveillance schedule? Do you continue on the high-risk schedule where they were at or bring them back to the start of the surveillance regimen?

A: Good question. I personally continue high-risk surveillance given the concerns of originally biology and more limited surveillance for low-risk.

Q: What are the next steps if the prostatic urethral biopsy is positive?

A: Depends on histologic findings. If non-invasive, can do TURP and BCG. (modified TURP allows BCG to get into prostatic fossa. If stromal invasive (T4a) then staging imaging, consider NAC then cystoprostatectomy.

Q: Maybe a comment on tumors located in bladder diverticula. If T1 - always partial cystectomy? If CIS also present, would recommend radical cystectomy? Thanks

A:No absolutes. Individualize for each patient. If CIS present more likely to perform cystectomy due to concern of field defect. Can consider diverticulectomy in carefully-selected patients – including low grade. Since no muscle, T1 is considered “invasive” in such patients

Q: Are you doing anything different on you BGC treatment during the shortage

A: Yes. Multiple adaptions. See https://suonet.org/resources/news/bcg-shortage-addressed-by-urologic-community.aspx

Q: In setting of BCG shortage, have you changed or altered your practice? if so, what alternatives are you using?

A: Yes. Multiple adaptions. See https://suonet.org/resources/news/bcg-shortage-addressed-by-urologic-community.aspx

Q: what trial/data is used to support the fact that you don’t need to do upper tract surveillance with low risk disease

A: No trial. Expert opinion balancing benefits (minimal/none in asymptomatic patient) versus risks (radiation exposure)