What do you do when metastatic urothelial cancer responds dramatically to systemic therapy? In this episode of BackTable Urology, Dr. Abhinav Khanna (Mayo Clinic) speaks with host Dr. Daniel Roberson about the growing question of consolidative surgery after enfortumab vedotin plus pembrolizumab. They discuss how EV-pembro has reshaped treatment expectations, why unexpected complete or near-complete responses are prompting tumor board debates about cystectomy, and how careful multidisciplinary decision-making guides which patients may be considered for surgery.

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SYNPOSIS

The conversation reviews early outcomes showing high rates of pathologic downstaging and the possibility that many patients may avoid additional systemic therapy after surgery, while emphasizing this approach is not yet standard of care. Dr. Khanna highlights coordination with medical oncology, radiology, and pathology, postoperative considerations, and the potential future role of biomarkers such as ctDNA. Ultimately, the episode underscores the need for clinical trials and thoughtful patient selection as clinicians navigate integrating surgery into an evolving systemic therapy landscape.

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TIMESTAMPS

00:00 - Introduction
02:19 - The Evolution of Urothelial Carcinoma Treatment
05:23 - Rationale for Consolidative Surgery
12:32 - Patient Selection Criteria
15:23 - Surgical Approach and Considerations
23:58 - Pathologic Findings
31:34 - The Role of Radiation
39:38 - Biomarkers
44:10 - Prospective Trials and Future Directions
53:06 - Guidance for Urologists

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RESOURCES

Consolidative Surgery for Advanced Urothelial Carcinoma Following Induction Enfortumab Vedotin and/or Immune Checkpoint Inhibitor Therapy: A Multicenter Analysis
https://pubmed.ncbi.nlm.nih.gov/40425390/

Enfortumab Vedotin and Pembrolizumab in Untreated Advanced Urothelial Cancer
https://www.nejm.org/doi/full/10.1056/NEJMoa2312117

Standard or Extended Lymphadenectomy for Muscle-Invasive Bladder Cancer
https://www.nejm.org/doi/abs/10.1056/NEJMoa2401497