How do you approach a patient with inoperable urothelial carcinoma of the bladder with persistent non-muscle invasive disease despite intravesical BCG/IFN and intravesical chemotherapy?

T1 high grade urothelial carcinoma, with persistent disease after intra-vesicular therapy (e.g., BCG) is an aggressive disease and progression to invasive urothelial cancer is common. This entity tends to be multifocal / diffuse and transurethral resection (TURBT) alone is often inadequate as definitive management with a high rate of local recurrence. Moreover, TURBT has a tendency to under stage the disease -- muscle invasive bladder cancer is commonly found at the time of radical cystectomy. In patients who are medically unfit for radical cystectomy, and without evidence of lymph node involvement or metastasis, curative intent treatment is warranted however there are currently few well-supported options available.

Definitive radiotherapy a...