How would you approach a patient considered to be unfit for cystectomy with recurrent NMIBC refractory to BCG, failed pembrolizumab and unable to do more intravesical Rx?  

This seems to be a very difficult scenario, what are the reasons for not being able to pursue intravesical therapies? Nadofaragene firadenovec just got FDA approval, while there have been data with intravesical gemcitabine/docetaxel. We are waiting for the FDA decision on N-803/BCG combo (QUILT-3.03...

Agree with Dr. @Grivas. If not able to proceed with cystectomy or further intravesical therapy, the use of trimodality therapy based on RTOG 0926 is reasonable acknowledging the limitations of the data, most notably the small sample size. The trial is promising with the 3-year freedom from cystectom...