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. --- 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. --- TIMESTAMPS 00:00 - Introduction02:19 - The Evolution of Urothelial Carcinoma Treatment05:23 - Rationale for Consolidative Surgery12:32 - Patient Selection Criteria15:23 - Surgical Approach and Considerations23:58 - Pathologic Findings31:34 - The Role of Radiation39:38 - Biomarkers44:10 - Prospective Trials and Future Directions53:06 - Guidance for Urologists --- RESOURCES Consolidative Surgery for Advanced Urothelial Carcinoma Following Induction Enfortumab Vedotin and/or Immune Checkpoint Inhibitor Therapy: A Multicenter Analysishttps://pubmed.ncbi.nlm.nih.gov/40425390/ Enfortumab Vedotin and Pembrolizumab in Untreated Advanced Urothelial Cancerhttps://www.nejm.org/doi/full/10.1056/NEJMoa2312117 Standard or Extended Lymphadenectomy for Muscle-Invasive Bladder Cancerhttps://www.nejm.org/doi/abs/10.1056/NEJMoa2401497