2. UroToday Home
  3. Video Lectures
  4. Bladder Cancer

Shifting From TURBT to Chemoablation in Low-Grade Intermediate-Risk NMIBC - Max Kates

November 18, 2025

Zachary Klaassen hosts Max Kates to discuss the role of intravesical mitomycin chemoablation for patients with low-grade intermediate-risk non–muscle invasive bladder cancer. Dr. Kates explains that these patients experience frequent recurrences with relatively low risk of stage progression but often benefit from active management when tumors become symptomatic, multifocal, or difficult to control. He reviews key clinical data for mitomycin chemoablation, highlighting high early response rates and durable disease control in appropriately selected patients. Dr. Kates emphasizes that chemoablation is particularly considered for patients in whom repeated TURBT has not provided durable control, rather than continuing the same surgical approach. He also discusses practical patient selection, including those on anticoagulation, patients with significant comorbidities, and older adults for whom multiple anesthetics may pose added risk.

Biographies:

Max Kates, MD, Division Director, Bladder Cancer Program, Urologic Oncology, Brady Urological Institute; Associate Professor of Urology, Johns Hopkins Medicine, Baltimore, MD

Zachary Klaassen, MD, MSc, Urologic Oncologist, Assistant Professor of Surgery/Urology at the Medical College of Georgia at Augusta University, Wellstar MCG, Georgia Cancer Center, Augusta, GA



Related Content:

UroGen Announces 24-Month Duration of Response of 72.2% from the Pivotal Phase 3 ENVISION Trial of ZUSDURI, the First and Only FDA-Approved Medicine for Recurrent Low-Grade Intermediate-Risk Non-Muscle Invasive Bladder Cancer

Mitomycin Reverse Thermal Gel Approved for Low-Grade Intermediate-Risk Bladder Cancer - Mark Schoenberg

Moving Beyond TURBT: Durable LG-IR NMIBC Control with Primary Chemoablation - Sandip Prasad

OPTIMA II Five-Year Data: Mitomycin Chemoablation Provides Durable Response in LG-IR-NMIBC - Neal Shore
Read the Full Video Transcript

Zachary Klaassen: Hi, my name is Zach Klaassen, Urologic Oncologist at the Georgia Cancer Center in Augusta, Georgia. I'm joined on UroToday by Dr. Max Kates, who is a urologic oncologist up at Johns Hopkins in Baltimore, Maryland. Today we'll be discussing UGN-102, and really starting to think about moving from TURBT to chemoablations for these low-grade intermediate-risk bladder cancer patients. So Max, thanks for joining us on UroToday.

Max Kates: Yeah, great to be here, Zach. Thanks for having me talking about an important subject that many of us see all the time.

Zachary Klaassen: Absolutely. No, you and I live a lot in the BCG unresponsive. There's been such a huge influx of options in BCG unresponsive non-muscle-invasive bladder cancer, but really just give our listeners a little background on what the natural history is of low-grade intermediate-risk disease.

Max Kates: Yeah, so low-grade intermediate-risk disease is a very different group of patients than say BCG unresponsive high risk. These patients, by and large, have frequent recurrences of low-grade non-invasive cancer. Progression to say invasive disease is very rare. I usually quote my patients single digits stage progression. Grade progression to high grade is a little more common, usually around 15 to 20% risk of a grade progression. But yeah, recurrence is incredibly common. A lot of these we see in the clinic all of the time. Many of them are, as we'll talk about appropriate for active surveillance and fulguration in the office. But many of these tumors bleed, many of them are multifocal and are growing, and we want to be able to manage these tumors before they have high-volume disease and become unmanageable. So there are many patients that need active management and treatment.

Zachary Klaassen: No, it's great background. And I think if we look at the UGN-102 story approved by the FDA in June of 2025, roughly about an 80% three-month complete response, it just came out with the durability of response. So durability at 24 months, if you're in that CR at three months is about 72%, which is pretty good. So the question leading into that is TURBT is kind of like Cysto, it's what urologists hang their hat on. If somebody's... You're talking to one of your colleagues, you're having a conversation, if they're hesitant about losing TURBTs, what would your message be to them for these patients?

Max Kates: My message would be that there's no bigger believer in a high quality TURBT than myself. And so right at the outset, I'm doing a high-quality TURBT and I am hoping that TURBT is diagnostic and most importantly curative. But guess what? This group of patients, it's often not. And so the group of patients that will benefit most from say an ablative technique such as UGN-102, are those patients where this first, oftentimes the second, maybe the third TURBT did not work. And so the last thing I want to do to a patient is try the same thing over again that by definition has not worked. And as surgeons, we want to get away from that. We want to do surgeries that work.

Zachary Klaassen: Yes, absolutely. No, and I think too, that patient that's having two or three TURs maybe in an 18-month stage, that can wear down patients too. I think that durability response at 72% really is impressive because we come from... If you look at that patient, they're probably having a recurrence or two in that time. And so you avoided maybe one or two TURBTs so when you're looking at patient first selection, you and I are just getting going with the process on formulary. What patients should listeners be looking for to get this process going? Like the low hanging fruit patients.

Max Kates: Yeah, I mean, I think the low hanging fruit patients are the patients first of all, you do not want to take to the operating room and you really don't think that active surveillance or fulguration is going to be good enough. And so these are patients that are on blood thinners. Where stopping the blood thinners is going to be a major issue. These are patients with many comorbidities. I mean, the average age of the patients that come into our clinic is 75. So there are quite a few patients like this. And those are patients that I'm going to try a non-surgical technique where they don't need general anesthesia, they don't need to come off of blood thinners, et cetera. So those patients derive benefit.

Zachary Klaassen: No, absolutely. I think ENVISION has told us too that even size greater than three centimeters is okay. Maybe just speak to maybe that multifocality, that field effect of treating the whole bladder.

Max Kates: Yeah, I mean, I think it's very interesting. I can speak... I don't love to speak anecdotally, but I did participate in the trial and one of my patients that was considered a non responder, so for the purposes of the trial, she actually had an eight centimeter tumor. And we were considering a radical cystectomy, which I hate to do and rarely do for low grade disease, but it was just unmanageable. It was unresectable. And after we did the treatment UGN-102, the tumor shrunk to two centimeters and I easily TUR'd it. And to this day, she has not had a recurrence and it's been many years. So I'm not suggesting that it be used for that. But I think it drives home the point that there's a lot of benefit to be derived by thinking about using these drugs to avoid the invasiveness of a TURBT.

And we know, we did a study at Hopkins just looking at TURBT, and we called patients one hour, two hours, four hours, eight, and then even 24 hours after their TURBT. And I think I do a pretty good job, but our unplanned visit to the clinic was 9%. Our ER visits were 5%. So one out of every 20 patients, I do a TUR on ends up in an ER, maybe not at my own institution, but another, and I don't think I'm unique. I think there's just a lot of... We don't take into account the toxicity of TURBT probably enough as urologists.

Zachary Klaassen: No, I think it's well said. You mentioned 75s are median age. You start adding up anesthetics on those patients too, and that can be really detrimental just to cognition and everything else. So I think that's well said. My last question really relates along the logistics of setting up this program. It's six treatments, there's no maintenance. How is your nursing staff approach this? What's the patient feedback in the trial or in your own experience? Just tell us about the logistics, maybe some words of wisdom.

Max Kates: Yeah. So we have, like many groups and many urology practices out there, we have a dedicated group of nurses that do our intravesical therapies. And to be honest, UGN-102, even though it's a different formulation, is like a gel, it's very similar to, say, BCG or intravesical chemo for those of us that do Gem/Doce, et cetera. So there's a slight difference that we had to train our nurses for the first instillation, but honestly, after they did one or two instillations, it's just like BCG. I'm not really around when they're getting it and it's kind of no big deal. Yeah.

Zachary Klaassen: And they're used to that weekly every six treatments anyways, so...

Max Kates: Yeah.

Zachary Klaassen: Max, always enjoy having you on UroToday. Thanks so much for your time. Any take-home points, including statements for our listeners?

Max Kates: No, I would just say that intermediate... We're entering a period in which there isn't a one-size-fits-all category. And that's very true for low-grade non-invasive cancer. We have a lot of tools at our disposal. We have, as I said, active surveillance. We have fulguration, we definitely have UGN-102 and we still have TURBT. And so how we use those tools for our patients, it should always be in the patient's best interest.

Zachary Klaassen: Absolutely. Well said Max. Thanks again.

Max Kates: Thank you.