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Advances in the management of localized bladder cancers

Nature Reviews Clinical Oncology (2026)Cite this article

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An Author Correction to this article was published on 19 January 2026

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Abstract

Bladder cancer remains a substantial global health burden. Localized, non-metastatic bladder cancer encompasses a spectrum from non-muscle-invasive bladder cancer (NMIBC) to muscle-invasive bladder cancer (MIBC). Advances in risk stratification, biomarker discovery and therapeutic innovation are reshaping the management of localized bladder cancers. Regarding NMIBC, enhanced cystoscopy techniques, en bloc transurethral resection and a multitude of novel systemic or intravesical treatment strategies, including immunomodulatory, viral, molecularly targeted and/or cytotoxic therapies as well as novel drug delivery mechanisms and chemoablation, are expanding treatment options, particularly for patients with Bacillus Calmette–Guérin-unresponsive disease. For patients with MIBC, refinements in surgical techniques and new neoadjuvant and/or adjuvant systemic therapies, particularly perioperative immunotherapy and potentially antibody–drug conjugates, continue to improve oncological outcomes. Bladder-preserving approaches such as trimodal therapy or even active surveillance following neoadjuvant therapy are also gaining clinical traction, offering selected patients with MIBC an alternative to radical cystectomy. Advances in the identification and application of circulating tumour DNA-based and tumour tissue-based biomarkers will help to further support personalized treatment and follow-up strategies. In this Review, we discuss progress and changes in the management of localized bladder cancer over the past decade and highlight ongoing innovations and future research directions that will shape clinical practice in the coming decade.

Key points

  • Urine biomarkers have not yet changed diagnosis and surveillance approaches for bladder cancer; cystoscopy remains the gold standard approach.

  • Management of non-muscle-invasive bladder cancer (NMIBC) relies on risk-adapted strategies, although recent guideline modifications reallocating small high-grade Ta tumours from the high-risk to intermediate-risk category remain controversial.

  • Therapeutic innovations are expanding treatment options for Bacillus Calmette–Guérin (BCG)-unresponsive NMIBC, with regulatory approval of pembrolizumab, nadofaragene firadenovec and nogapendekin alfa inbakicept. Several clinical trials are investigating other novel therapies for both BCG-unresponsive and BCG-naive NMIBC.

  • Radical cystectomy remains the standard-of-care treatment for muscle-invasive bladder cancer, with no clear differences in oncological outcomes between open and robotic-assisted approaches. Standard pelvic lymph node dissection is recommended, given that no survival benefit has been demonstrated with the use of an extended template.

  • Perioperative chemoimmunotherapy has demonstrated superiority over neoadjuvant cisplatin-based chemotherapy in patients with muscle-invasive bladder cancer and has therefore become a standard of care. Bladder-sparing approaches will become increasingly important as more-effective neoadjuvant therapies are introduced.

  • Detectable circulating tumour DNA after neoadjuvant therapy or radical cystectomy correlates with inferior clinical outcomes, supporting further investigations in ongoing trials to test the potential role of circulating tumour DNA status in guiding intensification or de-intensification of adjuvant therapy.

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Fig. 1: Pharmacological treatments for non-muscle-invasive bladder cancer.
Fig. 2: Progress in the treatment of non-muscle-invasive and muscle-invasive bladder cancer.

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  1. Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada

    Marie-Pier St-Laurent, Jussi Nikkola, Eisuke Tomiyama & Peter C. Black

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St-Laurent, MP., Nikkola, J., Tomiyama, E. et al. Advances in the management of localized bladder cancers. Nat Rev Clin Oncol (2026). https://doi.org/10.1038/s41571-025-01104-z

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