Systemic immunotherapy for BCG unresponsive nonmuscle-invasive bladder cancer

Purpose of review Treatment of Bacillus Calmette-Guérin (BCG)-refractory nonmuscle-invasive bladder cancer (NMIBC) is a significant clinical problem, with limited bladder-sparing strategies. The following review aims to show the recent advances in systemic immunotherapy that are transforming the treatment paradigm in patients with BCG-refractory NMIBC. Recent findings Developing evidence highlights the therapeutic success of immune checkpoint inhibitors, such as pembrolizumab and gene therapy, which received regulatory approval for high-risk BCG-refractory NMIBC. Combination regimens, with immunotherapy combined with intravesical therapy or chemotherapy, are under exploration to enhance treatment efficacy and bypass resistance. The identification of new molecular targets and the development of tailored strategies also depict the fast-paced evolution in this field. Summary Systemic immunotherapy is now of potential benefit in BCG-refractory NMIBC patients, providing viable bladder-sparing therapies. Our findings have significant implications for clinical practice and enable the transition to individualized, less invasive therapies. More work is required to optimize outcomes, expand therapeutic options, and improve quality of life in this challenging patient population.