Patients with low-grade Ta bladder cancer represent a challenge since they often have recurrences but have little overall risk to their health from these tumors. A recent retrospective review demonstrated a very low-risk of progression from low-grade to high-grade disease (8%).324 However, patients are often subjected to repeat TURBT’s resulting in increased health care costs, risks associated with repeat anesthetics, and the burden of scheduling and time commitment. There have been several reviews which have examined deintensification strategies. A few recent reviews examining strategies like in-office fulguration, active surveillance, and chemoablation found improved quality of life for patients as well as lower costs and less morbidity without compromising oncologic efficacy.325, 326 Prospective, randomized trials comparing surveillance office-based fulguration to operating room-based resection for small, papillary bladder tumors in low-risk NMIBC patients have not been completed. Several centers have reported on retrospective cohort series of office-based endoscopic fulguration of small bladder masses with acceptable oncologic outcomes.71, 327-329 While these cohort series varied in their inclusion criteria, in general, office-based fulguration was restricted to patients with known low-grade Ta disease in which the size of the tumor was small (typically defined as less than 0.5 to 1.0 cm). This suggests that selected patients with low-risk NMIBC and isolated, small, papillary recurrences may be effectively managed with office-based, endoscopic fulguration with local anesthesia and sedation. This has the potential to spare a patient the risks associated with anesthesia required for a more invasive resection in an operating room setting. In a recent retrospective study of 270 patients with recurrent Ta, low-grade NMIBC treated with office fulguration, the 10-year incidence of cancer-specific mortality and disease progression were 0% and 3.1% (95% CI: 0.8% to 5.4%), respectively.330 For highly selected patients, clinicians may opt for watchful waiting or conservative management in those patients for whom the risks of fulguration may outweigh the risks of disease progression. This might include those cases where in-office fulguration is not readily available or patients who require ongoing anti-coagulation. It should be noted that it does appear that patients with multiple TURs and/or multiple lesions may be at higher risk for disease progression and failing surveillance.331, 332 Several retrospective studies and meta-analyses suggest that risk stratification of low-grade tumors may help guide therapy.333 Patients with larger tumors (>3 cm), multiple tumors, and shorter times to recurrence (<1 year) have higher recurrence rates, and although still low, higher rates of progression. Therefore, when deciding on more conservative management, clinical features should be included in shared decision-making with the patient. A more recently approved option is the administration of UGN-102 for low-grade intermediate-risk bladder cancer. In the ENVISION trial, 240 patients received UGN-102 for recurrent low-grade NMIBC (intermediate-risk). The primary endpoint was a complete response rate at 3 months of 79.6% and a durable response rate of 82% at 12 months in those achieving a complete response rate.154 As a result of the trial, the FDA approved the use of UGN-102 for recurrent low-grade intermediate-risk NMIBC. However, the Panel felt several important caveats should be kept in mind. A fulguration or chemoablative approach that does not obtain tissue for pathologic evaluation should not be utilized unless a diagnosis of low-grade Ta disease or papillary urothelial neoplasm of low malignant potential (PUNLMP) has been previously established. A fulguration approach should be restricted to those patients in whom the lesion is papillary in appearance, rather than sessile or flat, and is no more than 1 cm in size. Furthermore, patients in whom a urinary cytology is suspicious for urothelial carcinoma are at higher risk for harboring occult high-grade disease and warrant pathologic evaluation of any visible lesion. Upper tract imaging to assess occult disease also may be considered in patients who develop repeated recurrences of small papillary lesions in the bladder.