Zachary Klaassen: Hi, my name is Zach Klaassen, urologic oncologist at the Georgia Cancer Center in Augusta, Georgia. We're at AUA 2025, in Las Vegas, Nevada on UroToday. Delighted to be joined by Dr. Katharina Oberneder, who is a urologist at the Medical University of Vienna. Thank you so much for coming to our meeting and for joining us on UroToday.

Katharina Oberneder: Thank you so much for the introduction.

Zachary Klaassen: So we're going to be talking today about a very important topic, looking at oncological outcomes among patients undergoing cystectomy after they've had BCG failure. And so maybe just to set the stage, talk to us about how much this disease space has changed in the last five years and how we shouldn't forget about cystectomy.

Katharina Oberneder: So we're definitely entering a new era of management of high-risk non-muscle invasive bladder cancer, especially for patients with BCG-unresponsive disease. However, if we look at our international guidelines, including the AUA guideline and the EAU guideline, the guidelines still recommend radical cystectomy as the gold standard for the treatment of BCG-unresponsive non-muscle invasive bladder cancer.

Zachary Klaassen: Yeah, absolutely. And we've seen multiple approvals for other therapies. But again, like you said, guideline-specific management, gold standard still radical cystectomy. So with that background, maybe just tell us about the study design you presented at AUA.

Katharina Oberneder: So this study, our analysis was conducted from a prospective multicenter register for bladder cancer patients. We included 141 patients from three academic centers across Europe. And our primary outcome was survival in patients treated with radical cystectomy for BCG-unresponsive disease.

Zachary Klaassen: Excellent. And so when you look at the results, just give us the highlights of your main findings from this study.

Katharina Oberneder: So I want to go into two results that are really important. So the first one being that a significant portion of patients is under-staged, with 35% of patients having muscle-invasive disease at radical cystectomy and 16% of patients having lymph node-positive disease at radical cystectomy.

Zachary Klaassen: Wow!

Katharina Oberneder: In these patients, in our total cohort, cancer-specific survival showed really favorable outcomes in these patients, with the cancer-specific survival being 96% at 12 months, 91% at 24 months, and 90% at 60 months after radical cystectomy.

Zachary Klaassen: Wow! That's great. I think this is really almost sobering data because when we think about staging patients with good TURBTs, with good imaging, and maybe offering them one of these new agents after BCG failure, this data is really important. And you nailed those two numbers that I pulled out-- was muscle invasive almost one-third of patients pathological N1 in 16%. So when you're talking to a patient in the clinic who's had BCG failure and you think about the options that are bladder-sparing, but you think about these data that you've presented with muscle invasive bladder cancer and pathological N1, how do we talk to our patients about this?

Katharina Oberneder: I think this highlights that firstly, there is a huge risk of under-staging as well as risk for progression. But we have to keep in mind that radical cystectomy is a life-altering procedure and it significantly affects quality of life for our patients. So we have to have an open and honest discussion with our patients, weighing the risk of progression with the risks associated with radical cystectomy to make a patient-focused, individualized decision for our patients.

Zachary Klaassen: Yeah. Great discussion. I think you nailed it there. It's shared decision-making. I think that's the key.

Katharina Oberneder: That's the key.

Zachary Klaassen: Maybe just a couple take-home messages for our UroToday listeners.

Katharina Oberneder: Yes, so I think my take-home message would be a significant number of patients is under-staged. Outcomes in patients treated with radical cystectomy for non-muscle-invasive disease have favorable oncologic outcomes. So we definitely need more reliable tools to accurately stage our patients. But I think the most important take-home message is radical cystectomy remains the gold standard for patients with BCG-unresponsive non-muscle invasive bladder cancer.

Zachary Klaassen: That's great. Katharina, great discussion. Congratulations on the data, and thanks for joining us on UroToday.

Katharina Oberneder: Thank you so much for having me. Thank you.