Zachary Klaassen: Hi, my name is Zach Klaassen, urologic oncologist at the Georgia Cancer Center in Augusta, Georgia. I'm delighted to be joined on UroToday by Dr. Katie Murray, who is a urologic oncologist at NYU in New York. Today we'll be discussing moving from TURBT to chemoablation for low-grade intermediate-risk, non-muscle-invasive bladder cancer. Katie, thanks so much for joining us on UroToday.

Katie Murray: Great. Thanks so much for having me, Zach. Always fun to chat with you and spend a little bit of time learning from you and talking back and forth about what we do in our practices.

Zachary Klaassen: Absolutely. And we'll be educating hopefully our listeners as well. And I know that's why we'll be talking about today because we've had a little shift from—we've been doing TURBTs forever, essentially as urologists. Before we get into that discussion, just level set for our listeners what the natural history of low-grade intermediate-risk disease is and why we need some new therapeutic options.

Katie Murray: I think it's important first to recognize bladder cancer—we're talking about non-muscle-invasive bladder cancer, and then more specifically how important grade is. We have low-grade and we have high-grade, and we're really diving into this low-grade population, but this low-grade intermediate-risk. What does that mean? It means people with larger tumors who are low-grade or multifocal tumors who are low-grade or recurrent tumors that are low-grade.

And really I think what you're asking is, "What's the natural history of that?" If somebody's diagnosed with low-grade bladder cancer, what are the chances of recurrence or becoming multifocal disease? And the unfortunate truth for these patients is this can be quite high. It can push up to 60% chance of recurrence for these individuals, which is why they become patients that we get to know very well. We see them often in our offices, we are cystoscoping them every three months, and then it starts stretching out over time. But we know these individuals because of the recurrent nature of low-grade bladder cancer. Now if it's identified and taken care of, the good part of low-grade bladder cancer is it does have a low risk of progression as long as you continue that evaluation and we're able to identify tumors when they occur and treat them appropriately.

Zachary Klaassen: That's a great background. As you know, June of 2025, we had UGN-102, ZUSDURI™, which was FDA-approved for chemoablation in this population, and we've talked multiple times on the site what that data means—roughly 80% complete response rate at three months, duration of response now, 24 months, is over 70%. Great trial and it's now in a lot of our clinics. Again, it's going back to the root of the conversation we've been doing TURBTs forever. One of those things we've been holding tight onto, but we have an opportunity here to treat the field of the bladder with UGN-102. What would you say to somebody listening who's like, "I'm always going to do a TURBT"? Why should we be exploring this? Why should they be considering it?

Katie Murray: I think there are a couple of things that I remind people when I think about this: TURBT is not going away. This is not replacing it forever. I realize how important it is in our practices. That's how we diagnose these patients.

You've got to get that initial diagnosis to see these patients are low-grade. You don't want to undergrade, you don't want to be treating a high-grade patient inappropriately. These patients are going to have a TURBT at some point in time, but when their natural history shows you that they're going to recur—three months later they recur, nine months later they recur, two years later they recur—and these tumors, because like you mentioned, that field defect, they really try to pop up around the bladder.

Historically, we just take these people to the OR, do another surgery and they're used to that. But that's where—that was our option. But now we do have ZUSDURI™ or UGN-102, and it's not just playing the whack-a-mole game where you're grabbing the tumors as you see them; you really are treating that whole bladder. And not taking away TURBT, but it's just something else in our armamentarium to offer that patient who continues to have recurrences. And we want to avoid having to take them to the operating room three, four, five times over a several-year time period. And like you just mentioned, if we do this as a pure chemoablation, which is the FDA approval, the three-month response rate—78%, close to 80%—which is great, but a TURBT can do a pretty good job of getting those numbers as well. But that duration of response, we know that recurrence risk can be pushing 60%. If we can get a duration of response where 70% of people have a durability of response for 24 months, that's what I like about it.

Zachary Klaassen: Totally agree. As you look at your patients in the clinic, the decision-making that goes into selecting patients—which patients are you looking for and how are you explaining this to them?

Katie Murray: Right now I really am looking at those patients with the recurrent low-grade disease. It is a little bit of a paradigm shift for our practice, but also for these patients—for these patients who have had repeat surgeries, when all of a sudden you're throwing in something different than what you've told them for the last five or six years, they're like, "Wait a minute. What are you talking about here, Katie?" or something like that. But what I've been doing actually is for every patient who has low-grade disease, when I scope them in the office, whether they have a recurrence or they don't, I'm just bringing up this concept of saying, "Hey, every time you've had a recurrence, you've asked me in the past, is there anything else? And I've been telling you no. We actually have something now. I hope you don't have another recurrence in the future, but if you do, we actually have something else to discuss now."

That's for those recurrent patients. And then the first-time diagnoses, which are not going to go away—there are so many patients with first-time diagnosis—I'm bringing it up from the get-go, meaning I'm saying, "We're going to take this out. The risk of recurrence is 60-ish percent, plus or minus, and if you have that recurrence, we are going to think about doing a chemoablation in the future to avoid having to take you to the operating room time after time."

Zachary Klaassen: That's really helpful, just setting the stage, getting it into the back of their mind so that if and when they have a recurrence, you've already discussed it. That's great. When we look at your practice and somebody's listening to our conversation and they're considering starting a UGN-102 program, what are maybe some of the logistical things that can be helpful? Any tips or tricks in getting this in? Obviously it's intravesical; our nurses are used to it, but anything from your experience?

Katie Murray: I think the key point is, as I would say, from getting it into your practice and utilization, it's pretty simple for what we're used to, meaning it's chemotherapy. We know how to discuss chemo in the bladder with patients, and our nurses know how to place catheters, know how to do the instillation. We know what instructions to tell them for wiping down the toilet, flushing the toilet once they go home. But I do always explain to patients and ensure that my nurses understand, or whoever's instilling understands as well, the concept of: you get the drug from your pharmacy or outside pharmacy, wherever you're going to acquire it, and there are individuals that can help you with that. It comes in this gel format. It goes on ice for about 10 minutes. You do have to have ice available in your practice. It goes on ice for 10 minutes and that turns it into a liquid.

I always say while you put it on ice for that 10 minutes, that's your prep time for the catheter, getting it into the bladder, ensuring the bladder is drained—that's going to buy you 10 minutes and then you're ready for the syringes to be put into the catheter. It happens over about a 60-second timeframe before it starts gelling up. It is important to not do it super slow because it does start to gel when it hits that room temperature and body temperature and getting it through the catheter. The catheter actually stays in place, maybe taped to the side of the leg or to the abdomen, taped in place or held in place for about 10 minutes after it's instilled.

That's a little different than what we've done for some of the other drugs, but that's just to ensure that the drug gets into the bladder and gels completely within the bladder itself before you're pulling it out through the urethra and to ensure that it is in place. But otherwise, it really goes in as a liquid pretty similarly from that aspect. It's a bluish-purple color; patients can see a blue-purple hue to their urine for up to 24 hours after the instillation, once a week for six weeks, no maintenance. It's a single six-week induction. I think that's nice for patients as well.

Zachary Klaassen: It's great. That's awesome. I think just the logistics of keeping that catheter in for 10 minutes, making sure it's fully solidified before pulling it out is really helpful. And again, I think patients like that because there is no maintenance. It's that six weeks, do your follow-up cystoscopy, you get them onto their surveillance after that. Always a great conversation. Katie, anything we haven't hit on? Any take-home messages you wanted to discuss before we wrap up?

Katie Murray: I don't think so. I think really when something new comes out, it does take us a bit to figure out how to get it into our practice. And I think bringing it up early with the new diagnosis patients and just throwing it out there to the recurrent patients, even if they don't have a recurrence today, in three or nine months, they might have a recurrence and then they can mull over the idea in their mind between now and the next recurrence.

Zachary Klaassen: That's a great point.

Katie Murray: The fortunate nature of bladder cancer.

Zachary Klaassen: Absolutely. Especially these ones too.

Katie Murray: That's right.

Zachary Klaassen: As we talked about that two-year durability, those patients would have a recurrence with TURBT pretty highly likely. I think this is a really effective, safe option for patients.

Katie Murray: And it really is. I remind patients, and I think the concept in my mind is it's treating the cancer and not just the tumor. And I think it's a very subtle thing for patients to understand, but when you explain it and say, "I can go in and I can do surgery and treat this tumor, or I can treat your bladder cancer," and that's a little bit of a different thing.

Zachary Klaassen: For sure. Very helpful. Katie, great catching up with you. Thanks for your generosity of your time, as always.

Katie Murray: Sounds great. Thanks.