A 62-year-old man presents with recurrent urinary tract infections and painless haematuria. Cystoscopy reveals a papillary lesion. Biopsy confirms high-grade non-muscle-invasive bladder cancer (HG-NMIBC), T1 stage. After TURBT and BCG induction (6 weekly instillations), he has persistent disease at 3-month cystoscopy. The most appropriate next step is:
- A Repeat BCG induction course (6 weekly instillations)
- B Switch to intravesical mitomycin C maintenance
- C Radical cystectomy (RC) — BCG-unresponsive HG-NMIBC with failed adequate BCG ✓
- D Start systemic pembrolizumab and defer cystectomy
Correct answer: C. Radical cystectomy (RC) — BCG-unresponsive HG-NMIBC with failed adequate BCG
Explanation
BCG-unresponsive disease is defined as persistent or recurrent HG-NMIBC following at least adequate BCG (induction + first maintenance cycle or two induction courses within 6 months). In this setting, radical cystectomy remains the gold-standard recommendation per AUA/EAU guidelines due to high risk of progression to muscle-invasive disease. Pembrolizumab (KEYNOTE-057) has FDA approval as bladder-sparing option for BCG-unresponsive CIS in patients ineligible for or refusing cystectomy.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.