Living with non-muscle-invasive bladder cancer (NMIBC) means making a lot of decisions. For many people, some of the most important choices involve treatment. Sorting through the different types of surgeries and medicines can feel overwhelming. Each option comes with its own potential benefits and side effects, and may fit into your treatment plan differently.

You don’t have to make these decisions alone. You and your doctor will work as partners through a process called shared decision-making. Your oncology team will consider the details of your tumor and your overall health. You’ll share your treatment goals and preferences and let them know what matters most to you.

In this article, we’ll cover seven types of treatment for NMIBC. For each option, we’ll explain the treatment goals, possible side effects, and the treatment process.

1. Transurethral Resection of Bladder Tumor

A transurethral resection of bladder tumor (TURBT) is usually one of the first treatments for NMIBC. That’s because it can both diagnose and treat the condition at the same time. TURBT is done through the urethra — the small tube that carries urine out of the body. Your doctor will insert a thin camera, along with a long tube and small tools, into the bladder to remove any visible cancer.

During TURBT, the doctor also takes small tissue samples for biopsy. These samples are looked at under a microscope to see how aggressive the cancer looks (tumor grade) and how deeply it has grown into the bladder lining (tumor stage). The cancer may appear as tiny fingerlike growths called papillary tumors, which tend to be low-grade tumors. It can also appear as carcinoma in situ (CIS), a high-grade form that has a higher risk of returning after treatment or becoming more serious.

A transurethral resection of bladder tumor (TURBT) is usually one of the first treatments for NMIBC.

Possible complications include mild burning during urination, small amounts of bleeding, or a short-term urinary tract infection (UTI). Read more about possible complications of TURBT.

2. Immediate Intravesical Chemotherapy

Right after TURBT, many people receive a one-time dose of chemotherapy placed directly into the bladder. This is called single-instillation intravesical chemotherapy. “Intravesical” means the medicine goes into the bladder, not into the bloodstream. The medicine is given through a thin tube called a catheter, left in the bladder for about one to two hours, and then drained out.

This treatment helps kill any tiny cancer cells left behind after surgery. The goal is to lower the chance of recurrence (when the cancer comes back). Studies show that giving this treatment within 24 hours after TURBT can reduce recurrence by 12 percent to 17 percent. Commonly used medicines include gemcitabine and mitomycin C.

This treatment is usually recommended for people with low-risk bladder cancer. Possible side effects include bladder irritation or burning during urination.

3. Intravesical Immunotherapy With Bacillus Calmette-Guérin

Intravesical bacillus Calmette-Guérin (BCG) therapy is a type of immunotherapy — a treatment that helps the immune system fight cancer. It’s instilled directly into the bladder once a week for six weeks. Many people then continue with maintenance BCG treatments for one to three years. Regular cystoscopies (bladder exams using a thin camera attached to a tube) are important to track how well the treatment is working.

BCG is the standard treatment for both intermediate-risk and high-risk NMIBC. It works by stimulating the immune system inside the bladder and creating inflammation that helps destroy cancer cells. Although BCG has been used for over 50 years, it doesn’t work for everyone.

Side effects of BCG therapy may include bladder irritation, burning during urination, fever, chills, or tiredness.

4. Multidose Intravesical Chemotherapy

Multidose intravesical chemotherapy delivers cancer-fighting medicine directly into the bladder once a week for several weeks. Some people also get monthly maintenance doses for up to a year.

This treatment is often used for people who have intermediate-risk NMIBC or who can’t receive BCG. It may also be an option if the cancer returns after BCG treatment. Some chemotherapy drugs, such as gemcitabine, may help reduce the risk of the cancer coming back.

Possible side effects include bladder irritation, burning when urinating, or needing to urinate more often.

5. Gene Therapy

Nadofaragene firadenovec (Adstiladrin) is a type of gene therapy placed directly into the bladder every three months. It carries a copy of a gene that tells bladder cells to make interferon, a natural protein that helps the immune system fight cancer cells. This drug is the first gene therapy approved for NMIBC by the U.S. Food and Drug Administration (FDA).

This treatment is approved for people with high-risk, BCG-unresponsive NMIBC. It can be used in people with CIS with or without papillary tumors. In one study, 53 percent of people had no signs of cancer three months after treatment. Possible side effects include bladder spasms, urgency, or leakage.

Read more about treatment options if bladder cancer doesn’t respond to BCG therapy.

6. Systemic Immunotherapy

Immunotherapy is a type of treatment that harnesses a person’s own immune system to find and attack cancer cells more effectively. Some bladder cancers “hide” from the immune system by using a “checkpoint” — a shield formed by two proteins called PD-1 and PD-L1. Some types of immunotherapy for bladder cancer, known as checkpoint inhibitors, block this shield so the immune system can work better.

Pembrolizumab

Pembrolizumab (Keytruda) is an FDA-approved intravenous immunotherapy for NMIBC that blocks PD-1. It’s given every two to six weeks. In studies, some people’s cancer disappeared for several months, although not everyone responds.

This medicine is an option for people with high-risk, BCG-unresponsive NMIBC, especially those with CIS or who aren’t good candidates for radical cystectomy (bladder removal surgery). It may also be used for people who can’t tolerate other bladder-based treatments. The main goal is to control high-grade disease and avoid bladder removal when possible.

Other Checkpoint Inhibitors

Other checkpoint inhibitors may be used for more advanced bladder cancers. Avelumab (Bavencio) and durvalumab (Imfinzi) block PD-L1, which can help the immune system attack tumors. Nivolumab (Opdivo) blocks PD-1, which can help shrink tumors, slow cancer growth, or help prevent the cancer from returning after surgery. These drugs may be used after chemotherapy, before or after cystectomy, or if the cancer has spread.

Interleukin-15 Receptor Agonist

Nogapendekin alfa inbakicept (Anktiva) is an interleukin-15 receptor agonist — another type of immunotherapy. This drug boosts the immune system by activating natural killer cells and T cells, which are types of immune cells that attack cancer. It may be given along with BCG therapy if that treatment alone isn’t working.

Researchers are also studying new immunotherapy drugs in clinical trials. These studies aim to improve outcomes for people with BCG-unresponsive NMIBC by combining or replacing BCG with newer treatments.

Possible side effects include tiredness, diarrhea, rash, and thyroid changes. Your healthcare team will schedule follow-up visits to monitor you for more serious reactions.

7. Radical Cystectomy

A radical cystectomy is surgery to remove the entire bladder. It’s usually recommended for people with high-risk NMIBC when other treatments stop working or the cancer keeps coming back after BCG therapy. Some people choose this option because it offers the best chance of preventing the cancer from invading the muscle of the bladder (because the bladder is gone), a stage that’s harder to treat. Cystectomy may also be considered when the cancer grows, returns quickly, or shows signs that it may soon progress.

Radical cystectomy is a major operation. If it’s being considered, your doctor will talk with you about your overall health, your goals, and what recovery may look like. The main goal of radical cystectomy is to remove all cancer and lower the risk of it spreading.

After the bladder is removed, the surgeon creates a new way for urine to leave the body. There are three common options:

• Ileal conduit — Urine drains through an opening in the belly into a small bag worn on the outside of the body.
• Continent reservoir — Urine collects in a pouch inside the body and is emptied a few times a day using a thin tube.
• Neobladder — A new bladder is made from part of the intestine. This approach lets some people urinate the usual way, through the urethra.

Your surgeon will help you understand which option may be the best fit for your lifestyle, preferences, and overall health.

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