<p><strong> </strong><strong>In patients with recurrent low-grade NMIBC, clinicians may perform a transurethral resection/fulguration, use an intravesical chemoablative agent, or manage with active surveillance. (<em>Conditional Recommendation; Evidence Level: Grade C</em>)</strong></p>
Discussion
Discussion
<p>Patients who have multiple low-grade tumors, larger low-grade tumors, or recurrent low-grade tumors fall into the intermediate-risk group. Multiple options exist for patients who have a previously confirmed low-grade tumor and experience a recurrence of a papillary tumor which appears to be low-grade. A TUR of the recurrence has been the standard approach for these patients; however, a number of studies have now been published looking at alternative strategies. Intravesical chemoablation has been shown to provide acceptable rates of disease control. Two trials examining the use of UGN-102, a reverse thermal mitogel, have demonstrated complete response rates of up to 80% in the ENVISION trial and a 72% disease-free survival at 15 months in the ATLAS trial.<sup>152-154</sup> The principal benefit of UGN-102 appears to be the reduction in repeat surgical interventions rather than a direct comparison in efficacy to TURBT. Therefore, it may represent an alternative to repeat TURBT. In addition, several other agents have been studied as chemoablation and a recent meta-analysis demonstrated a pooled complete response rate of 50.9%.<sup>155</sup>. Several studies have also demonstrated the safety of de-escalation treatments including in-office fulguration and active surveillance.<sup>155, 156</sup> </p>