Hyperthermic intravesical chemotherapy for Bacillus Calmette-Guérin-unresponsive nonmuscle-invasive bladder cancer

Hyperthermic intravesical chemotherapy (HIVEC) and other device-assisted platforms are emerging bladder-sparing options after Bacillus Calmette-Guérin (BCG) failure in nonmuscle-invasive bladder cancer (NMIBC). This review integrates recent mechanistic, clinical and economic evidence to clarify their therapeutic position.

Prospective and real-world series in BCG-unresponsive disease report complete response rates of 40-60% for carcinoma in situ and 35-70% 12-24-month high-grade recurrence-free survival for papillary tumors. Radiofrequency-induced thermo-chemotherapy, recirculant chemohyperthermia and electromotive drug administration achieve comparable efficacy. Toxicity is usually grade 1-2 urinary urgency, frequency or dysuria, with serious events in fewer than 10% of patients. Health-economic modelling suggests HIVEC becomes cost-effective once high-grade recurrence-free survival exceeds 30% at 12 months.

Device-assisted hyperthermic chemotherapy combines biological plausibility, acceptable safety and favorable cost, positioning it as a potential option between BCG failure and radical cystectomy. Ongoing phase III trials will determine long-term oncological control, refine patient selection and optimize sequencing with systemic and intravesical agents.