Introduction:

The management of BCG-unresponsive non–muscle-invasive bladder cancer (NMIBC) remains a significant global challenge, particularly amid ongoing BCG shortages and the lack of consistent guidelines for alternatives to radical cystectomy (RC) in patients who are unfit for or decline surgery. This study examines real-world clinical practices across the US, Europe, Asia, and the Arab world to evaluate the extent of variability in treatment approaches. Gaining insight into these real-world patterns in urologist practices is essential for identifying current gaps in care and guiding the development of standardized research protocols and clinical trials that better reflect practical realities. Such efforts are critical to improving outcomes for patients with BCG-unresponsive disease

Methods:

To examine global treatment practices for BCG-unresponsive NMIBC, we conducted a structured literature search using MeSH terms and keywords such as “BCG-unresponsive,” “BCG failure,” “treatment patterns,” and “survey.” The search was restricted to English-language articles and excluded abstracts without full-text availability. Of the 55 articles identified, 5 met the inclusion criteria based on clinical relevance and a focus on provider-level treatment decisions by country. Data were organized according to key survey questions, and responses were compiled accordingly. Although not all surveys addressed identical questions, supplementary data from other sections were used to fill gaps, allowing for a more comprehensive overview of real-world treatment approaches of BCG-unresponsive disease. Descriptive statistics were used to summarize participant responses, with categorical variables reported as frequencies and percentages

Results:

Data were analyzed from multiple regions: Europe, the US, China, Japan, and Arab countries (Figure 1). In the US, 53% of providers reported using intravesical chemotherapy, followed by radical cystectomy (RC) at 27%, systemic therapy at 14%, and other approaches (6%), such as repeat BCG and re-resection. In Arab countries, RC was the most common choice (50%), followed by intravesical chemotherapy (30%), repeat BCG (12%), and re-resection (8%). European practices varied widely: RC (15–67%), intravesical chemotherapy (4–27%), systemic therapy (5–17%), re-resection (24–46%), and watchful waiting (up to 60%). In China, 64% used intravesical chemotherapy, 23% systemic therapy, 39% watchful waiting, and only 7% RC. In Japan, 49% opted for watchful waiting, 35% for re-resection, 11% for intravesical chemotherapy, and 13% for RC. Biopsy and fulguration were used by 10–25% of respondents in Europe, 16% in Japan, and 36% in China (Figure 2).

Conclusion:

Management strategies for BCG-unresponsive NMIBC vary markedly across regions. While intravesical chemotherapy is commonly employed in the US and parts of Asia, RC remains the dominant approach in the Arab world and several European countries. Notably, recently FDA-approved agents for BCG-unresponsive disease have seen limited adoption in clinical practice, highlighting a disconnect between regulatory advancements and real-world implementation. These disparities underscore the urgent need to investigate the factors driving global treatment preferences for this disease entity and to better understand why clinical practice varies so widely across regions, often diverging from established guidelines.

Funding: N/A