High-risk non-muscle-invasive bladder cancer (HR-NMIBC) represents a biologically aggressive disease state with substantial risk of recurrence, progression, and need for radical cystectomy. While intravesical Bacillus Calmette-Guérin (BCG) remains first-line for HR-NMIBC is standard of care, both recurrence and progression have led to the development of novel intravesical agents therapies. This article summarizes key clinical trials that are reshaping the management of HR-NMIBC, with particular emphasis on BCG-unresponsive disease. Approved intravesical and systemic agents demonstrate meaningful response rates and durable disease control in select patient populations. Emerging therapies and combination intravesical chemotherapies further expand the available therapies.

This comprehensive review examines using artificial intelligence (AI) across the diagnostic, therapeutic, and prognostic landscape of bladder cancer. It highlights AI's capacity to enhance tumor detection, histopathologic interpretation, surgical precision, and personalized treatment planning through machine learning and computer vision. Applications such as AI-assisted cystoscopy, cytology, transurethral resection of bladder tumor optimization, and prognostic modeling demonstrate significant potential to reduce variability and improve clinical decision-making. While early evidence is promising, widespread implementation requires rigorous validation, multicenter collaboration, and regulatory standardization. Ultimately, AI represents a paradigm shift toward data-driven, precision-based bladder cancer management which can potentially transform patient outcomes globally.

Non-muscle invasive bladder cancer represents the majority of bladder cancer cases and imposes a significant economic burden due to high recurrence rates and intensive surveillance. Cost-effectiveness analyses help compare treatment strategies, but integration into clinical guidelines remains limited. Financial toxicity affects many patients, particularly those with lower income. While novel therapies and diagnostic tools show promise, their cost-effectiveness is variable. Future efforts should focus on incorporating cost-utility data into guidelines and addressing both direct and indirect costs to optimize care and reduce financial strain for patients and health care systems.

Approximately 75% to 80% of cases are nonmuscle-invasive bladder cancer (NMIBC), an often chronic condition with high recurrence rates necessitating lifelong surveillance and repeated interventions. Despite contemporary favorable 5-year cancer-specific survival ranging from 71% to 96%, patients experience substantial physical, psychological, and financial burdens due to the significant and invasive follow-up monitoring and treatment of recurrences. TURBT and adjuvant intravesical therapy remain the cornerstone of treatment of NMIBC, and we discuss some innovations within this space, with novel agents and new techniques. Further, we focus on symptom management for patients undergoing therapy and enhancing bladder cancer survivor's quality of life.

Non-muscle-invasive bladder cancer (NMIBC) requires repeated procedures, long-term surveillance, and sustained access to urologic care. Outcomes are highly sensitive to health disparities. This article examines how social determinants of health including insurance status, socioeconomic factors, gender, ethnicity, geography, and care fragmentation can impact NMIBC care. Delays in hematuria evaluation, underuse and inequitable distribution of intravesical therapy, and decreased surveillance adherence contribute to higher recurrence, progression, and worse quality-of-life outcomes. These disparities may be driven primarily by differences in care delivery rather than tumor biology. Targeted system-level and policy interventions are needed.

Bladder cancer is the fourth most common cancer in males, and roughly 75% of new bladder cancer is non-muscle-invasive. Traditional surveillance protocols are costly and time-intensive for patients. Some studies report that more than half of patients with low-risk bladder cancer undergo too many surveillance procedures, and one-third of the patients with high-risk bladder cancer do not undergo enough procedures. As technology improves, surveillance protocols may deintensify the use of cystoscopy and incorporate less invasive alternatives. There is a great deal of ongoing research in noninvasive tests that may be used for surveillance in the future.

High-risk non-muscle-invasive bladder cancer represents a biologically heterogeneous disease with wide variation in recurrence and progression risk, creating persistent challenges in diagnosis, risk stratification, and management. Current guidelines rely on well-described clinicopathologic features to define risk; however, these factors alone often incompletely predict individual patient outcomes and efforts to refine prognostication using molecular profiling and advanced imaging techniques such as multiparametric MRI are under active investigation. Complete transurethral resection (TUR), including restaging TUR in appropriate patients, remains essential for both diagnosis and management.

Nonmuscle-invasive bladder cancer (NMIBC) is a clinically heterogeneous disease, characterized by a high recurrence rate and a progression risk that are challenging to predict. Although traditional risk models based on histopathology and clinical staging are widely used, their ability to inform personalized treatment remains limited. Recent advances in molecular profiling have provided a more comprehensive understanding of NMIBC biology. This article synthesizes current evidence regarding the molecular determinants, highlighting their roles in enhancing prognostication and informing personalized therapy. Integrating these molecular insights into contemporary risk stratification frameworks is enabling treatment strategies that align with tumor biology to optimize patient outcomes.

Bacillus Calmette-Guérin (BCG) remains the cornerstone adjuvant therapy for intermediate-risk and high-risk non--muscle invasive bladder cancer, yet its clinical utility is increasingly challenged by supply shortages, treatment intolerance, and variable oncologic response. This article summarizes the immunologic basis, efficacy, and limitations of BCG, examines evidence for alternative administration strategies, evaluates combination and biomarker-based approaches to optimize patient selection, and outlines emerging therapies for BCG-unresponsive disease. Practical, evidence-driven recommendations are provided to guide contemporary management during periods of constrained supply and evolving therapeutic landscapes.

Non-Muscle-Invasive Bladder Cancer poses significant therapeutic challenges due to high recurrence and progression rates. While intravesical Bacillus Calmette-Guérin (BCG) has long been the standard, limitations in efficacy, global shortages, and patient-specific contraindications to radical cystectomy have fueled the development of novel bladder-sparing therapies. Recent advances include UGN-102 for low-grade/intermediate-risk disease and multiple FDA-approved agents-nadofaragene firadenovec, TAR-200, and nogapendekin alfa inbakicept-for BCG-unresponsive disease. Ongoing trials of TAR-210, cretostimogene, and other combination regimens promise to further expand options. Comparative studies and real-world evidence will be critical to define optimal sequencing, benchmark outcomes against radical cystectomy, and address quality-of-life considerations.

White-light cystoscopy (WLC) may miss small, non-papillary, flat lesions, commonly associated with high-grade lesions such as carcinoma in situ. Enhanced cystoscopy techniques, including blue-light cystoscopy (BLC), narrow-band imaging, and IMAGE1 S, aim to address the shortcomings of traditional WLC in detecting bladder cancer. These techniques enhance the detection of tumors, although whether the improved sensitivity translates into better recurrence-free and progression-free survival is less certain. BLC should be utilized in patients with suspicious cytology and unrevealing WLC.

Transurethral resection of bladder tumor (TURBT) remains the foundation of nonmuscle invasive bladder cancer (NMIBC) diagnosis and treatment. The article covers preop evaluation (history, imaging, vesical imaging-reporting and data system, multiparametric MRI, office cystoscopy, and biomarkers), anesthesia/energy choices to limit obturator reflex/perforation, and operative technique using enhanced cystoscopy and selective en bloc resection (EBRT). It stresses meticulous specimen handling, immediate use of intravesical chemotherapy, and indications for second-look TURBT. Despite progress, incomplete resection and understaging are frequent; and broader use of visualization technologies, EBRT in selected cases, and quality programs are key to reducing recurrence and progression of NMIBC.

Urothelial carcinoma is a rapidly evolving field. An important area of recent advancement is in the diagnosis and surveillance of nonmuscle invasive bladder cancer (NMIBC). Approximately 75% of newly diagnosed bladder cancers are nonmuscle invasive. At least half of the NMIBC diagnoses are categorized as low-risk disease, for which surveillance and bladder-sparing treatments are recommended.