TURBT with Blue Light Cystoscopy and NMIBC Intravesical Therapy
TURBT (transurethral resection of bladder tumor) is the foundational procedure for diagnosing, staging, and treating non-muscle invasive bladder cancer (NMIBC). A rigid cystoscope is passed through the urethra, the visible bladder tumor is resected, and the muscle layer is sampled to determine whether the cancer has invaded. The pathology that comes from a TURBT determines everything else: risk stratification, intravesical therapy choice, and whether radical surgery is needed.
Dr. Wei Phin Tan performs TURBT with blue light cystoscopy at NYU Langone Health, Main Campus in Manhattan, and offers the full contemporary menu of intravesical therapies for NMIBC, including BCG, gemcitabine-docetaxel (BRIDGE protocol), Anktiva (N-803), Adstiladrin (nadofaragene firadenovec), pembrolizumab (Keytruda), Inlexzo (gemcitabine intravesical drug delivery system), and Zusduri (UGN-102, mitomycin reverse-thermal hydrogel).
"Bladder cancer is one of the most rapidly evolving fields in urology. Patients today have options that did not exist five years ago. The right plan depends on grade, stage, prior treatments, and how the bladder has responded so far."- Dr. Wei Phin Tan, MD, MHS, FACS
What Blue Light Cystoscopy Adds
Blue light cystoscopy (also known as Cysview, hexaminolevulinate, or HAL) is a contrast-enhanced imaging technique used during cystoscopy and TURBT. About one hour before the procedure, hexaminolevulinate is instilled into the bladder. It is selectively taken up by cancerous cells and converted to a fluorescent compound. Under blue light, cancer cells glow red while normal mucosa appears blue. Compared with standard white light alone, blue light cystoscopy improves detection of:
- Carcinoma in situ (CIS), which is often flat and difficult to see on white light
- Small papillary tumors that may otherwise be missed
- Multifocal disease at the time of initial TURBT or during surveillance
- Improved completeness of resection, lowering early recurrence rates in published series
Blue light is most useful at the initial diagnostic TURBT, in patients with positive cytology and unrevealing white light, and during surveillance in patients with a history of CIS or recurrent NMIBC.
How TURBT Is Performed
- Anesthesia: general or spinal anesthesia, outpatient or short-stay procedure
- Rigid cystoscopy with white light, then blue light when indicated
- Complete resection of visible tumor down to the detrusor (muscle) layer to allow accurate staging
- Biopsies of suspicious areas, prostatic urethra, and selected sites when CIS is suspected
- Single-dose intravesical chemotherapy (mitomycin or gemcitabine) within 6 hours after TURBT in selected patients to reduce recurrence
- Foley catheter typically removed within 1 to 2 days; most patients go home the same day
Risk Stratification After TURBT
After TURBT, NMIBC is grouped by AUA risk strata to guide treatment:
| Risk group | Typical features | Standard initial therapy |
|---|---|---|
| Low risk | Solitary, small (<3 cm), low-grade Ta, no prior recurrences | Single-dose intravesical chemotherapy after TURBT, surveillance |
| Intermediate risk | Recurrent low-grade, multifocal, larger Ta low-grade | Induction intravesical therapy (mitomycin, gemcitabine, BCG) ± maintenance |
| High risk | High-grade Ta, T1, CIS, BCG-unresponsive features | BCG induction + maintenance or BCG-alternative regimens (gem-doce, Anktiva, Adstiladrin, Keytruda, Inlexzo) |
Risk stratification is general. Individual recommendations depend on pathology, prior treatments, and the patient's overall medical condition.
NMIBC Treatment Pathways
Dr. Tan offers the full contemporary spectrum of NMIBC therapies. Each therapy below is a distinct entity with its own FDA-approved indication, mechanism, and clinical scenario. The right choice is matched to the patient's grade, stage, BCG history, and goals.
First-Line Therapy for High-Risk NMIBC (BCG-Naive)
BCG (Bacillus Calmette-Guérin)
The longest-established and most studied immunotherapy for high-risk NMIBC. Standard induction is 6 weekly instillations followed by maintenance dosing. BCG remains first-line for high-grade Ta, T1, and CIS in BCG-naive patients with a functioning bladder.
Gemcitabine + Docetaxel (BRIDGE Protocol)
Sequential intravesical gemcitabine and docetaxel has emerged as a strong BCG-alternative regimen, particularly during BCG shortage. Dr. Tan and the NYU Langone urologic oncology team are participants in the BRIDGE trial evaluating gem-doce head-to-head against BCG in high-risk NMIBC.
Chemoablation for Low-Grade Intermediate-Risk NMIBC
Zusduri (UGN-102, Mitomycin Reverse-Thermal Hydrogel)
Zusduri is FDA-approved for chemoablation of low-grade intermediate-risk NMIBC, a separate clinical scenario from high-risk or BCG-unresponsive disease. It allows tumors to be treated without TURBT in selected patients. The reverse-thermal hydrogel is liquid at room temperature, gels in the bladder, and holds mitomycin against the urothelium for several hours before passing in the urine. This is the only FDA-approved therapy that can ablate low-grade intermediate-risk NMIBC tumors as a primary treatment.
BCG-Unresponsive High-Grade NMIBC
For high-grade NMIBC (CIS, with or without papillary disease) that has not responded to BCG and where the patient is not pursuing or is ineligible for cystectomy, four FDA-approved options are now available. Each is a distinct entity with a different mechanism. Selection is individualized to disease pattern, prior treatment, comorbidity, and patient preference.
Anktiva (N-803, nogapendekin alfa inbakicept) + BCG
FDA-approved IL-15 superagonist combined with BCG for BCG-unresponsive NMIBC with CIS. Anktiva amplifies the immune response to BCG and has shown durable complete responses in pivotal trials.
Adstiladrin (nadofaragene firadenovec)
Non-replicating adenovirus-based intravesical gene therapy delivering interferon alfa-2b directly to bladder cells. FDA-approved for BCG-unresponsive high-grade NMIBC with CIS, with or without papillary tumors. Administered every 3 months.
Pembrolizumab (Keytruda)
Systemic PD-1 checkpoint inhibitor, FDA-approved for BCG-unresponsive high-grade NMIBC with CIS in patients who are ineligible for or have elected not to undergo radical cystectomy. The only systemic option in this group.
Inlexzo (Gemcitabine Intravesical Drug Delivery System, "Gemcitabine Pretzel")
Inlexzo is a small, pretzel-shaped device placed inside the bladder that releases gemcitabine continuously for several weeks at a time. Originally developed as TAR-200, Inlexzo is the FDA-approved trade name. The sustained-release design delivers continuous intravesical chemotherapy without repeated weekly office instillations, and is offered for BCG-unresponsive NMIBC in appropriately selected patients per FDA-approved indications.
When TURBT Is Not Enough
For muscle-invasive bladder cancer (T2 or higher), or for high-grade NMIBC that fails to respond to intravesical therapy, the standard of care is robotic radical cystectomy with urinary diversion. Bladder-sparing trimodal therapy (TURBT + chemotherapy + radiation) is also offered in carefully selected patients in coordination with radiation oncology and medical oncology.
Surveillance After NMIBC
- Cystoscopy and urine cytology every 3 months for the first 2 years, then less frequently based on risk and disease behavior
- Blue light cystoscopy as indicated, especially with a history of CIS or recurrent disease
- Upper tract imaging (CT urogram) periodically to monitor for upper tract urothelial cancer
- Repeat TURBT if surveillance shows new or recurrent tumor
Selected Evidence (Dr. Tan's Published Work)
Dr. Tan has published extensively on TURBT quality, intravesical therapy, hyperthermia, and surveillance for non-muscle-invasive bladder cancer.
- Gallagher K, MacLennan S, Bhatt N, et al. RESECT: A Randomised Controlled Trial of Audit and Feedback in Non-muscle-invasive Bladder Cancer Surgery. European Urology. 2026. PMID 41444076
- Shah A, Tan WP, Inman BA. National Quality Improvement Program in Transurethral Resection of Bladder Tumor. European Urology. 2020. PMID 32788045
- Tan WP, Longo TA, Inman BA. Heated Intravesical Chemotherapy: Biology and Clinical Utility. Urologic Clinics of North America. 2020. PMID 31757301
- Tan WP, Plata Bello A, Garcia Alvarez C, et al. A Multicenter Study of 2-year Outcomes Following Hyperthermia Therapy with Mitomycin C: HIVEC-E. Bladder Cancer. 2022. PMID 38994184
- Tan WP, Chang A, Brousell SC, et al. Safety and efficacy of intravesical chemotherapy and hyperthermia in the bladder: results of a porcine study. International Journal of Hyperthermia. 2020. PMID 32664768
- Grimberg DC, Shah A, Tan WP, et al. Hyperthermia Improves Solubility of Intravesical Chemotherapeutic Agents. Bladder Cancer. 2020. PMID 36118287
- Wang Y, Chang A, Tan WP, et al. Diet and Exercise Are not Associated with Skeletal Muscle Mass and Sarcopenia in Patients with Bladder Cancer. European Urology Oncology. 2021. PMID 31133436
- Tan WS, Tan WP. Urinary biomarker for the detection of recurrence following non-muscle invasive bladder cancer: are we there yet? Translational Andrology and Urology. 2018. PMID 29644175