Abstract
BACKGROUND AND OBJECTIVE: As more clinicians adopt alternatives to radical cystectomy (RC) for Bacillus Calmette-Guérin (BCG)-unresponsive non-muscle invasive bladder cancer (NMIBC), understanding how these approaches are applied in practice is essential. To explore global treatment trends, we analyzed regional surveys on BCG-unresponsive NMIBC management. METHODS: A structured literature review identified four published provider-based surveys, along with a fifth, unpublished survey conducted by our team in collaboration with Romanian colleagues. These included an international survey (January-May 2019) of 508 physicians from eight countries (Europe, Japan, and China); a 2022 U.S. national survey (n=259); and a regional Arab survey (October-November 2023; n=106 across 14 countries). Additional national surveys were conducted in Saudi Arabia (n=19; April-May 2024) and Romania (n=216; May-June 2025). Responses were grouped by key questions and analyzed using descriptive statistics. KEY CONTENT AND FINDINGS: For treating BCG-unresponsive disease, urologists in the U.S. and Saudi Arabia mainly followed guidelines from the American Urological Association (AUA). Romanian urologists, by contrast, primarily adhered to European Association of Urology (EAU) guidelines. Across Arab countries, practices reflected a mix of recommendations from the EAU, AUA/Society of Urologic Oncology (SUO), and the National Comprehensive Cancer Network (NCCN). Treatment approaches for BCG-unresponsive disease varied widely across regions. Intravesical chemotherapy was most frequently used in the U.S. and China, whereas RC was the preferred option in Romania and many Arab countries. In Japan, clinicians favored watchful waiting, resection, and surveillance, with limited use of RC. European physicians similarly leaned toward conservative strategies, mirroring Japanese urologist approach. Preferences for intravesical chemotherapy agents differed by region: gemcitabine (Gem) was commonly used in the US and Arab countries; epirubicin and doxorubicin were favored in China; mitomycin C (MMC) was preferred in Europe. While most urologists were familiar with gemcitabine/docetaxel (Gem/Doce), its actual use in clinical practice remained limited. Barriers to intravesical chemotherapy use in this setting were mainly due to unclear clinical guidelines. Notably, at the time of the surveys, newly Food and Drug Administration (FDA)-approved therapies like nadofaragene and pembrolizumab were rarely used. CONCLUSIONS: Global practice patterns for BCG-unresponsive disease vary widely across regions, highlighting the need for a more unified, consensus-driven approach to the use of evolving bladder-sparing therapies and clinical guidelines.