Good morning, ladies and gentlemen, and thank you for standing by. Welcome to UroGen Pharma's fourth quarter and full year 2021 financial results and business update conference call. It is now my pleasure to turn the call over to Vincent Perrone, Senior Director of Investor Relations for UroGen Pharma. Please go ahead.
Thank you, operator. Good morning, everyone, and welcome to UroGen Pharma's fourth quarter and full year 2021 financial results and business update conference call. Earlier this morning, we issued a press release providing an overview of our recent corporate highlights and financial results for the quarter and year ended December 31st, 2021. The press release is available on the investors portion of our website at investors.urogen.com. Joining me on the call today are Liz Barrett, President and Chief Executive Officer, Dr. Mark Schoenberg, Chief Medical Officer, Jeffrey Bova, Chief Commercial Officer, and Molly Henderson, Chief Financial Officer. During today's call, we will be making certain forward-looking statements. These may include statements regarding the success and timing of our ongoing commercialization of Jelmyto, planned clinical trials, data presentations, regulatory filings, future research and development efforts, manufacturing capabilities, and 2022 financial guidance, among other things.
These forward-looking statements are based on current information, assumptions and expectations that are subject to change. A description of potential risks can be found on our earnings press release and latest SEC disclosure documents. You are cautioned not to place undue reliance on these forward-looking statements, and UroGen disclaims any obligation to update these statements. I'll now turn the call over to Liz. Liz?
Thank you, Vincent, and thank you to everyone joining us today. We remain focused on developing novel solutions for urothelial and specialty cancers, with the goal of fundamentally transforming the treatment paradigm for what is largely an underserved patient population. In this pursuit, I am proud of the progress we've made throughout 2021 and in early 2022, further solidifying Jelmyto's place in the market as the only FDA-approved non-surgical treatment for low-grade UTUC and setting the stage for several important commercial and clinical milestones in the year ahead. Despite challenges on our commercial efforts stemming from the global COVID-19 pandemic, we continue to help new patients gain access to Jelmyto, which is a testament to the resilience and perseverance of our commercial team.
Growing patient access and awareness continue to drive adoption of Jelmyto as we set new records for revenue, new patient enrollment, and site activations in the fourth quarter, setting us up for strong growth in 2022. Jeff will provide more detail on our commercialization efforts, but at a high level, our commercial team did an excellent job adapting to added challenges placed on the healthcare system by rising cases of the Omicron variant as well as staff shortages in Q4. This led to an all-time quarterly high in new product revenue of $16.2 million in Q4, a 42% increase over Q3. Total net product revenue for 2021, our first full year of product sales of Jelmyto, was $48 million, which was in line with guidance. Molly will review our financial results and provide guidance for 2022 shortly.
However, we remain confident in the outlook for the business as we expect continuing and accelerating adoption of Jelmyto in our second full year post-launch. Late last year, we announced the launch of a pilot named Named Patient Program for Jelmyto, which included five European countries, France, Germany, Switzerland, Austria, and the U.K. During the fourth quarter of 2021, we continued to expand this program with the addition of Australia to the pilot. The NPS program, in partnership with Neopharm in Israel, saw the identification of the first four patients with product for two of those patients delivered to Neopharm in Q4. I'm pleased to report that as a result of these efforts, two of these Israeli patients received Jelmyto, representing the first time patients outside of the U.S. have been treated with Jelmyto in a commercial setting.
Beyond Jelmyto, we made important progress in the clinic, advancing our lead development program, UGN-102, and positioning UGN-301, our immuno-oncology program, for human trials. Turning first to UGN-102, which is in development to treat low-grade intermediate-risk non-muscle invasive bladder cancer, an indication impacting approximately 80,000 underserved patients in the United States annually. Last month, we initiated the phase III ENVISION trial, a single-arm, open-label pivotal trial, which replaced the previously announced phase III ATLAS trial. ENVISION is similar in design to the phase II OPTIMA II trial, and as a result, we believe carries a very high probability of success. I'm pleased to report that earlier in the first quarter, we completed the shift to ENVISION, opening the first clinical site and recently dosing the first patient.
We expect ENVISION to complete enrollment by the end of 2022, and assuming positive findings, we anticipate submitting an NDA in 2024. Importantly, UGN-102, if approved, would share a prescriber base with Jelmyto, which would ensure an efficient and expedient product launch. We continue to believe Jelmyto and UGN-102 together represent well over $1 billion revenue opportunity for UroGen, and the start of the ENVISION trial moves us closer to realizing the full potential of these two highly promising innovative therapies. For UGN-301, we announced results from a toxicology study, which formed the foundation of an IND application we submitted to the FDA last month, putting our first RTGel-based immuno-oncology candidate on track to initiate a first-in-human study in the first half of 2022. Mark will discuss plans for our multi-arm combination study that represents a unique approach to treating high-grade bladder cancer.
We recently closed an up to $100 million senior secured term loan facility with funds managed by Pharmakon Advisors. This non-dilutive capital gives us the financial flexibility to continue expanding our commercial and development efforts. Based upon our current financial projections, provides us with what we believe to be the necessary runway to reach cash flow breakeven by 2025. Pharmakon Advisors have been great partners, and this facility demonstrates their belief in the impact our company can have on patients, and I want to thank them for their partnership. Finally, I want to address a disclosure made earlier today announcing a transition in our financial leadership team, as Molly has decided to leave her role as CFO of UroGen to assume a broader role with another company.
Molly led our efforts and successfully strengthened our balance sheet, leaving us well positioned to continue advancing our strategic vision. While Molly will be missed, it is a good time to transition her finance responsibilities to her successor, Don Kim, currently Vice President of Finance, who will assume the CFO role effective March 25th. Don is a seasoned financial professional with extensive biopharma industry experience. Prior to joining UroGen, Don held leadership positions with Zoetis, Sun Pharma, and most recently with Strides Pharma, where he served as Head of Finance and as a member of the Board of Directors. Lastly, given the critical role investor relations continues to play in our success, this function will now report directly to me.
At UroGen, one of our primary goals is to give patients better options by continuing to shift the treatment paradigm in uro and specialty oncology away from repeated surgeries and disease management to minimally invasive therapeutic ablation of tumors and locally administered immunotherapy approaches. We expect 2022 to be a pivotal year for UroGen as we expect a more normal environment with Jelmyto's launch to fully enroll our pivotal study for UGN-102, which represents a major advancement in care for patients and a billion-dollar revenue potential for our company, to expand our development efforts into immunotherapy with a unique combinatorial approach for high-grade disease. I'm extremely proud of the progress we continue to make toward our goal of bringing novel solutions to patients that deserve better. With that, I'll turn the call over to Mark to discuss our recent clinical and development updates. Mark?
Thank you, Liz. Before providing an update on our recent progress advancing our clinical development programs, UGN-102 and UGN-301, I'd like to comment on a recently published retrospective analysis in The Journal of Urology, which reported real-world experience utilizing antegrade administration of Jelmyto. The study was conducted by Dr. Katie Murray of the University of Missouri School of Medicine and provided a stepwise treatment approach to antegrade administration of Jelmyto. Dr. Murray and colleagues showed that antegrade installation provided a well-tolerated and effective method to administer Jelmyto, which did not negatively impact patient comfort. Importantly, Dr. Murray's analysis suggests that antegrade administration, which minimizes manipulation of the ureter during installation, may help protect against stricture formation that had been reported following repetitive instrumentation of the upper urinary tract.
As previously stated, Jelmyto is approved for both retrograde and antegrade administration, and both methods can be performed as an outpatient procedure in the clinic. However, installation via retrograde administration requires administration by a physician via a ureteral catheter utilizing fluoroscopic guidance, whereas antegrade administration may be performed by a trained nursing professional and does not require fluoroscopy prior to Jelmyto installation once nephrostomy tip position is confirmed. Dr. Murray and her colleagues offer practical guidance for antegrade administration of Jelmyto, which may simplify Jelmyto administration for both patients and physicians. Switching to UGN-102, I'm pleased to report that since our last update, we have completed the transition from the ATLAS study to the recently initiated phase III ENVISION pivotal trial. ENVISION is designed as a single-arm, multinational, multi-center study evaluating the efficacy and safety of UGN-102 as primary tumor ablated therapy in patients with low-grade intermediate-risk NMIBC.
Importantly, we believe ENVISION carries a higher probability of success given it does not require a control arm comparing UGN-102 to surgery. In addition, the design of ENVISION is similar to our phase II-B OPTIMA II study of UGN-102, which showed a complete response rate of 65% and durability at 12 months of 72.5%. As Liz noted, we recently began dosing patients in ENVISION. The study, which is being conducted at over 90 sites, is expected to enroll approximately 200 patients who receive once weekly intravesical instillations of UGN-102. In terms of the evaluable patient population, ENVISION will enroll patients with low-grade recurrent intermediate-risk NMIBC. The primary endpoint will evaluate the complete response rate 3 months after the first installation, and the key secondary endpoint will evaluate durability over time in patients who achieve a complete response at the three -month assessment.
Based on our estimations, which include feedback from the FDA, we expect full enrollment by the end of 2022 and assuming positive findings, we anticipate submitting a new drug application in 2024. In addition to the ENVISION study, we are conducting a single-arm at-home installation study of UGN-102 with the goal of demonstrating the feasibility of home installation. We believe offering an at-home solution for low-grade intermediate-risk non-muscle invasive bladder cancer patients is an important step in solving access to care and quality of life issues that many elderly patients may face with the current standard of care transurethral resection of the bladder tumor or TURBT. We expect to enroll up to 10 patients in the next six months. Low-grade intermediate-risk NMIBC remains a significant unmet need, affecting an estimated 80,000 patients in the United States.
There are no FDA-approved therapies for this disease, leaving repeated TURBT as the current standard of care. We believe UGN-102 has the potential to transform how we treat these patients, in particular, those at risk for recurrence and those that are unwilling or unable to undergo surgery or general anesthesia by becoming the first viable non-surgical alternative for low-grade intermediate-risk disease. I'm also pleased to provide an update on our progress in our immunotherapy program, which includes the development of an anti-CTLA-4 antibody that we are developing to treat high-grade non-muscle invasive bladder cancer. UGN-301 is our in-licensed anti-CTLA-4 antibody that we are advancing alongside our clinical development partners at MD Anderson Hospital. UGN-301 is in development for the use as monotherapy and in combination with immunomodulators and chemotherapies to treat high-grade non-muscle invasive bladder cancer.
CTLA-4 has long been considered a good target for overcoming immune suppression produced by tumor cells. Unfortunately, the systemic administration of checkpoint inhibitor antibodies to this molecule is associated with dose-limiting toxicity. We believe that intravesical delivery via RTGel may permit us to leverage the power of our highly potent anti-CTLA-4 monoclonal antibody, UGN-301, while avoiding the toxicity associated with systemic administration. Last month, we announced the completion of an IND-enabling toxicology program, which formed the foundation of an IND submission supporting the initiation of a multi-arm phase I clinical study of UGN-301, which we expect to begin during the first half of this year. The objective of this study is to establish safety and dose ranges for UGN-301 as monotherapy and in combination with other agents, including UGN-201, our TLR7 agonist, which has demonstrated single-agent activity in high-risk non-muscle invasive bladder cancer patients.
The first arm of the phase I study will evaluate UGN-301 as monotherapy and will take approximately 12 months to complete. We view UGN-301 as a fundamental checkpoint inhibitor and the cornerstone of a variety of potential combination therapies targeting high-grade cancers. We are excited to begin evaluating its potential in the clinic this year and look forward to updating you on our progress. Lastly, we plan to continue research efforts to identify additional medicines that may work with our proprietary technology to advance care across urothelial and other specialty cancers. We are in the process of prioritizing the most promising targets and hope to share more about our plans later this year. With that, I would like to turn the call over to Jeff to provide a commercial update. Jeff?
Thank you, Mark. I'm pleased to provide you with an update on our ongoing commercial rollout of Jelmyto. As Liz mentioned, we achieved a quarterly record of $16.2 million in net product sales in the fourth quarter, representing a 42% increase from quarter three. Revenue for 2021, our first full year on the market, was $48 million. Despite volatility in certain regions throughout the year, which corresponded with the rise of COVID-19 cases, Jelmyto full-year revenue trends were favorable in 2021. I'm pleased to report that the momentum which we ended the third quarter continued through to Q4 and into 2022.
With our field force primarily back to engaging with physicians in person, we've observed a more consistent ramp-up in new patient starts and patient enrollment forms on a week-to-week basis thus far in 2022 compared to some of the variability we saw in the same period last year. We're hopeful this is suggestive of a more normalized launch trajectory for Jelmyto in 2022. As we look ahead, we anticipate similarities to last year with respect to sequential quarterly variance heading into Q1, which is attributable for the most part to deductible resets typically seen in the first quarter. However, we expect strong year-over-year revenue growth despite seasonality, which is expected with a buy-and-bill product such as Jelmyto.
I'm particularly pleased with the growing enthusiasm and adoption for Jelmyto we are seeing from physicians, as our data suggests steady growth in both new and repeat prescribers. The number of activated sites as of March 1st was 832, up from 706 on November 1st, 2021, and representing an increase of 17%. Importantly, the number of repeat accounts or sites that have treated more than one patient increased to 106 from 86 on November 1st, 2021. This represented an increase of 23%. As the number of repeat accounts has grown, we've seen a significant improvement in conversion times from new patient enrollment forms to the patient being treated from 40 days down to 20 days, which is expected as accounts identify more patients and have an established treatment protocol in place.
Steady growth in both of these critical areas gives us confidence we will continue to see rising adoption of Jelmyto and suggests a positive treatment experience from the perspective of both physicians and patients. We are pleased to announce that the VA has created a criteria for use for Jelmyto. The CFU establishes a streamlined pathway by which HCPs can access Jelmyto to treat low-grade UTUC within the VA system, representing a significant milestone and another opportunity to continue to drive penetration within the VA. I remain highly encouraged by what we're seeing in adoption and engagement, and remain optimistic that we'll continue to see favorable trends during the remainder of 2022. Lastly, we continue to make progress with the UTRAC patient registry.
At this time, we are finalizing the build with feedback from the urology community and onboarding of initial sites with an expected phased launch before the end of Q1. Data collected in this study is expected to evaluate real-world outcomes of UTUC patients treated with Jelmyto, provide insight into the long-term treatment benefits, and evaluate its use in clinical practice in the U.S. We look forward to providing additional updates on this program, including select findings later this year. With that, I'd like to turn the call over to Molly for a review of the financials. Molly.
Thank you, Jeff, and thank you to everyone for joining today's call. Before reviewing our fourth quarter and year-end 2021 financial results, I'd like to touch upon the up to $100 million non-dilutive term loan financing we recently announced with funds managed by Pharmakon Advisors. We are pleased to partner with Pharmakon, an experienced specialist investor with a strong track record of supporting innovative life science companies. In Pharmakon, we have a partner who believes in the opportunity of Jelmyto and its ability to positively impact the treatment landscape of low-grade UTUC, as well as the broader potential for our pipeline of innovative therapies to address significant unmet needs in urothelial and specialty cancers.
The up to $100 million senior secured term loan facility significantly strengthens our financial position and supports our operating needs with what we believe will be sufficient runway to achieve cash flow breakeven by 2025, based on our current revenue projections and financial models. The first tranche of $75 million was received last week and will immediately begin for our continued commercialization efforts of Jelmyto and our ongoing phase III single arm ENVISION trial of UGN-102. At our discretion, we may draw upon an additional $25 million before the end of the year. The loan will mature in five years from the initial funding, and we reserve the right to prepay the loan in its entirety at any time, subject to certain prepayment premiums and make-whole amounts.
In return, we will make quarterly interest-only payments to Pharmakon for the first 48 months of the repayment period, followed by principal and interest payments, with interest accruing using three-month LIBOR with a 125 basis point floor plus 8.25%. Once again, we're excited to partner with Pharmakon, an experienced industry leader committed to supporting innovative biotech companies. I'll now review our financial results for the fourth quarter and full year ended December 31st, 2021. As Liz and Jeff mentioned, UroGen reported net product sales of Jelmyto for the fourth quarter of 2021 of approximately $16.2 million, aggregating to $48 million for the full year 2021. This compares to $8 million and $11.8 million, respectively, in the same periods of 2020. The increase driven by the launch of Jelmyto in June of 2020.
As Jeff mentioned, we are anticipating somewhat lighter revenues in the first quarter of 2022 as compared to Q4 of 2021 due to the potential seasonality and deductible resets. In saying that, we are anticipating Q1 2022 revenues to be stronger than Q1 2021 by at least 50% and in line with our expectations and forecasting. Cost of revenues for the fourth quarter 2021 were approximately $1.6 million, resulting in gross margin of 90%, compared to gross margin 92% in the fourth quarter of 2020. Full year 2021 cost of revenues were $5.2 million, resulting in full year gross margin of 89%, compared to 91% for 2020.
Research and development expense for the fourth quarter and full year ended December 31st, 2021, were $13.1 million and $47.6 million, compared to $12.4 million and $47.3 million, respectively, for the same periods in 2020. Research and development expense includes $900,000 and $4 million in non-cash share-based compensation expense for the fourth quarter and year ended December 31st, 2021, as compared to $1.4 million and $6.4 million, respectively, for the same period in 2020. The increase in R&D expense in 2021 was related to the phase III ATLAS trial for UGN-102, which was initiated at the end of 2020.
Selling, general, and administrative expense for the fourth quarter and year ended December 31st, 2021, were $21.4 million and $87.5 million, respectively, compared to $22.2 million and $90.2 million, respectively, for the same periods in 2020. Selling, general, and administrative expense includes $4.5 million and $19.1 million of non-cash share-based compensation expense for the fourth quarter and year ended December 31st, 2021, compared to $5.1 million and $21.6 million for the same period in 2020. Before moving on, I'd like to take a moment to comment on our operating expenses. Since the beginning of 2021, we tripled net product revenues while at the same time exercised effective cost management and fiscal responsibility to allow us to invest in areas of the business that support patients gaining access to our important therapies.
As a result, we were able to reduce SG&A in 2021 without adversely impacting our commercial and clinical activities. As we look to the remainder of 2022, we expect consistency in SG&A and higher spend in R&D related to ongoing phase III ENVISION trials and anticipated UGN-301-01 phase I studies. In the fourth quarter ended December 31st, 2021, the reported financing expense related to the prepaid forward obligation of RTW Investments was $7.3 million and $17.3 million for the full year. As the transaction closed in May of 2021, there were no similar expense in 2020. The total cash payments that was made to RTW for 2021 are approximately $4 million.
Lastly, as it relates to RTW, the rate in which our payments will be made to them in 2022 will increase from 9.5% to 13% based on the global net product sales of Jelmyto in 2021. For the fourth quarter and year ended December 31st, 2021, we reported a loss of $28.5 million, or $1.27 per share, and $110.8 million or $4.96 per share, respectively. This compares to net losses of approximately $30.5 million or $1.38 per share, and $128.5 million or $5.90 per share for the same period in 2020.
The net loss for the fourth quarter and year ended December 31st, 2021, includes $5.4 million and $23.1 million, respectively, in non-cash share-based compensation expense, compared to $6.5 million and $28 million for the same period in 2020. We closed the year with $89.8 million in cash equivalents, and marketable securities. This does not include the first tranche of $75 million we received on the term loan facility with Pharmakon. Turning to our financial guidance for 2022. We anticipate full year 2022 net product revenues from Jelmyto to be in the range of $70 million-$80 million, representing a 46%-67% increase over 2021 revenues.
We anticipate our full year 2022 operating expenses to be in the range of $140 million-$160 million, including non-cash share-based compensation expense of $10 million-$16 million, subject to market conditions. Lastly, we anticipate full year 2022 financing expense related to the prepaid obligation to RTW Investments in the range of $22 million-$26 million, of which an estimated $9.1 million-$10.4 million will be in cash. Lastly, I'd like to take a moment and address Liz's earlier comments. I'm proud to have played a role in bringing Jelmyto to market in the development of UGN102. Both programs have the potential to transform the treatment paradigm of low-grade UTUC and low-grade intermediate risk NMIBC.
With a newly strengthened balance sheet and an exceptional team in place, I remain confident in the team's ability to continue executing UroGen's strategic vision. I'd like to thank Liz and the board of directors of the company. I'm excited to transition the CFO position to Don Kim, a very capable and experienced leader who has demonstrated the highest level of professional competence. With that, I'd like to turn the call over to questions. Operator?
Our first question comes from Boris Peaker with Cowen.
Good morning, and thank you for taking my question. My first question may be on the ENVISION studies. Can you comment what it is you need to show ultimately for approval and if there is any kind of meaningful value for partial responders?
Mark, do you wanna take that and I'll add any commentary?
Yeah, sure. Boris, thanks for the question. Well, as you know, the current study is almost identical to our phase II in design and in terms of the target population. We are lucky to be able to rely on what we saw in phase II to guide us as to what we might expect in the phase III. Just to remind the listeners, in the phase II, the complete response rate was 65% with the durability by Kaplan-Meier at a year of approximately 73%. You know, we think that's a good guide to what we might see in this trial. Obviously, we have to do the trial.
We think those are compelling data and helpful in terms of thinking about what to expect from this trial. I suspect Liz may wanna comment as well.
Yeah, I mean, I think, look, we have said all along before we ever saw the results of our first study. Our phase II study was, you know, we felt like somewhere around 50% and 50% durability would be meaningful. The FDA hasn't given us guidance to say, specifically, "You have to hit this number." What they've said, "It's gotta be clinically meaningful." So what they will do, and you know, we will do, you know, as well, is they'll be in contact with key opinion leaders in the urology field to say, "Do you believe that this is meaningful?" And as we've talked about before, likely go to an ODAC.
Which we feel very good about because we have physicians who've said if it weren't for any patient, you know, to have the option, you know, would like to have the option. While we can't comment when we actually don't have a specific number, we feel confident that even if we're anywhere in this 50% range and 50% range, that that would be clinically meaningful.
The second part of my question, is there any kind of clinical meaningfulness in the partial responders from the-
Yeah. Sorry about that.
Yeah, practically.
Yeah, sorry, I didn't. Mark may want to comment as well. Yes, we believe there is. Actually, what we're capturing is in this study, which we had not captured much before, but we actually went back and looked at some data. You know, the ability to get a partial response actually also allows you to avoid a TURBT and can be managed more conservatively when you've gotten a partial response. That's what we've seen so far in the data. But you know, we also believe that both for Jelmyto and UGN-102, that's an area we need to study. What if we get a partial response? What if you gave two more instillations? You know, would that make a difference? We plan to study that.
To your point, yes, we see a benefit, even in partial responders. Mark, was there anything else to add?
No, I thought that was it. Thanks.
Great. Thank you very much for taking my question.
Thanks, Boris.
Next. Our next question comes from Chris Howerton with Jefferies.
Hi. Good morning. Thank you so much for taking the questions. A couple from me this morning. First of all, I wanted to know, maybe from a commercialization perspective on Jelmyto, I know a lot of the efforts that you've made, Jeff, in the past has been focusing on clinics and physicians and kind of creating an opportunity for them to prescribe Jelmyto when and if a UTUC patient becomes available. But I guess I'm curious if you've made any efforts on the patient demand side and if you could make any comments on that. Secondarily, I'd also like to know if you've been able to observe any meaningful changes in practice procedures with relation to either surgical ablations or radical nephroureterectomies. Excuse me.
If I may, the last question, perhaps a parting question for Molly. Just curious if you could give us a little more color as to, with respect to the cash flow break-even thinking in 2025. Thank you.
Jeff, you wanna take first, and then Molly can chime in.
Sure. Thanks, Chris. Yeah. We are increasing our level of patient marketing for 2022 and the end of 2021 because yes, you pointed out if patients could be aware of Jelmyto as an option, that's ultimately what we wanna see more of. We do have more in regards to social media activation, patient awareness, as much as we can do while being responsible from a resource perspective. Obviously, we want everyone to know about this, but given the patient population, we're certainly doing a lot to activate the patients. I do know we have some, you know, some various things in the offices where patients will go in in the waiting room, they'll be able to scan a QR code, learn more about Jelmyto.
We do a lot through both the website as well as recognition, you know, getting them to go to the website for Jelmyto and utuc.com, which is an unbranded site that really is not just for our patients, but our physicians use that as a resource to talk to their patients about their disease. We are doing more, and we'll continue to do more in 2022. Regarding your second question, yes, obviously the good thing here is RNUs, what we've seen in market research are going down. We continue to wanna partner with endoscopic resection.
Physicians, you know, will use Jelmyto in different ways with endoscopic resection in place of but the good things that we've seen in the past 2-3 years is radical nephrectomy are coming down for patients with low grade, which is obviously what we would set out to do. Hopefully I answered. Molly, do you wanna take the second question?
Sure. As it relates to the cash flow break even projection by 2025, obviously, Chris, that's contingent upon our current models for revenues and expenses. Based upon where we currently see the demand for Jelmyto, we believe that, with our current infrastructure and the support that we have from the commercial team, that we can get to cash flow break even by 2025. That does obviously factor in a little bit, from UGN-102 in the event we're successful with getting approval by the end of 2024. As we've always said, we do believe that we can be a standalone business on Jelmyto alone.
We feel comfortable that again, with the funding that we have from Pharmakon and the cash we have on hand, that we have a path to get there.
Okay. Awesome. Well, thank you very much. Jeff, yes, that did address my question. Thanks again.
Sure. Thanks, Chris.
Our next question comes from Paul Choi with Goldman Sachs.
Good morning, everyone. This is Charlie on for Paul. Thank you so much for taking our questions. First question from me is just looking for a little bit more color maybe on the 2022 revenue guidance and wondering what are the pushes and pulls that dictate the upper and lower bounds of that guidance. My second question was just regarding the future UGN-301 combinations and whether we should be expecting UGN-201 to kind of be the priority combination partner there, or maybe we should be expecting some other potential partners coming in in the near future. Related to the combination trial with UGN-301, should we be expecting that any combination arm wouldn't be started until completion of the monotherapy arm with that monotherapy data in hand? Thank you.
Jeff, why don't you take the first one and I'll add any commentary, and then we can turn it over and Mark can take the second question.
Sure. Thanks, Charlie. Yeah, so with regards to the guidance for this year, I mean, obviously one big factor is always COVID-related issues. You know, as I've stated, we're starting to get back to a little bit of normal with face-to-face interaction with physicians. That is key for any drug in this launch phase, but certainly for a rare disease. Anything there that could impact you know elective surgeries is certainly gonna have an impact on the number. That's probably the biggest factor. I think, you know, we're gonna start to see some additional data from the registry that I mentioned. If, you know, hopefully, obviously, that data once we have that, we'll go out discuss it.
Depending on what it shows, that could certainly give us an opportunity there. Continuing on that, more data that we have on nephrostomy administration, that continues to grow in as far as the main route of administering versus retrograde. As we start to generate data there, and publish that and get that out there, you could see that grow even further in 2022, probably maybe even faster than expected. Those are sort of the highs and lows. Liz, did you wanna comment?
Well, I guess my only thing, Jeff, and you talk about it quite often, is really the depth and breadth of accounts, right?
Sure.
We have to continue to do both of those. We have to continue to get new accounts on board that, you know, have said they're going to use. You know, the thing is, the other thing about what Jeff said, it's not only, you know, from a standpoint of having the rep go in, but it's, you know, it's an installation, so it's a very high touch sell. Them being able to go in there and work the account is important. You kinda have to hold their hand, you know, until they're used to the account. Doing both from an adoption perspective, both breadth and depth. Which Jeff talks about often. Mark, do you wanna just talk about the combination study?
Sure. Thanks. Yes, we will be starting with 301. It's a phase I dose escalation study, and we need to acquire some information from first in human use from that experience. However, our team has developed a very elegant overlapping combination protocol that will permit us to start combinations before the complete conclusion of the phase I with 301. We will start that before the completion. As to whether or not we would use 201 first as opposed to another agent, the answer is we are actively exploring that. We do plan to use 201 currently, and we are doing some preliminary in-human work to verify that that's the best thing for us to do.
We are also actively looking at other potential combination partners for 301. There's going to be more to tell about that within the next year or so. Liz may want to comment as well.
Yeah, I was just gonna say we'll follow the science. Whether 201 will be the primary will depend on the work, you know, the work that we do. The intention is to have several. It's intention is not just to do combination with UGN-201, but potentially chemotherapy and other targeted agents, both targeted agents as well as other immuno-oncology agents. You know, we think that's what the team is working through now, and the work that we're doing at MD Anderson will, you know, help to identify which combinations are best appropriate. Again, the idea is to test, you know, quite a few of them so we can see what works best and then move forward with those combinations.
Great. That's very helpful. Thank you all very much.
All right, thanks. Thank you.
Our next question comes from Ram Selvaraju with H.C. Wainwright.
Thanks very much for taking my questions. Couple of quick financial ones first. I was wondering if you could comment on the specific revenue level that you expect to be commensurate with achievement of cash flow breakeven in 2025, and if you expect this revenue level to necessarily be above $200 million. Secondly, I also wanted to confirm whether that guidance effectively assumes that you would be able to discharge your debt repayment obligations to Pharmakon even as a standalone business solely focused on Jelmyto. You know, if that's hypothetically a scenario that would also be possible.
Sure. I'll take those, Ram. First question on the revenue level. What we've always said is that we believe we can achieve peak market share of around, you know, 25%-35% for Jelmyto. If you assume that based upon what we believe and what we've always indicated as a total potential opportunity of about $700 million, you can get to where we see that peak opportunity to be, which is probably right around the range that you're referring to, in 2025. As it relates to the Pharmakon prepayment, we do believe that the success of UGN-102 would be important for us to be able to make sure that we can make that payoff at that five-year mark.
In saying that, you know, Pharmakon is obviously a great partner, and if we feel like we need a little bit more extension, I'm sure we can have a discussion with them at the time. Right now, we feel very comfortable that we can achieve that payment in five years. To your point, we do need to have some movement from the UGN-102 side in order to make sure we can fully pay that back.
Okay. Just on
Stay within the cash breakeven.
Got it. Just on 301, I was wondering if you could comment on. Well, actually, before I ask the 301 , I forgot one other thing. Can you comment on potential ex-US opportunities for Jelmyto? Not necessarily in Europe, which I know is a subject that you've touched upon before, but in other countries simply based on, you know, now the knowledge base that's been gathered in the United States, it appears to be a more and more accepted product. You know, what could we potentially realistically expect, from an ex-US perspective, you know, from a partnership, from a distribution standpoint, for the products, in, you know, in the coming months, quarters and years?
Yeah. It's Liz. I think the priority for us is gonna be Japan, because we know two things about Japan. One, we know exactly what needs to be done, and we know that we can get good reimbursement. That will be our priority. I mean, we've, to be honest with you, we've had a lot of interest in, you know, China and, you know, some other smaller, you know, the Middle East. Frankly, we have to balance, you know, sort of the price, you know, the revenue we can get, the price that we can get in those markets, you know, with the effort and, you know, we're still working through that.
We don't, you know, we haven't found yet a good analog that gives us the opportunity to be able to get a decent reimbursement. We really focus and which is the reason for the Named Patient Program, right? We did that because what happens is, in these markets, and I've experienced this in my past, is, you need champions. You need the physicians and patients to be going to the payers and saying, "We want access to this medicine." Then they'll consider, you know, giving you a more innovative price. We'll continue to work through that. I would say the priority is Japan. Obviously, you know, if we find an opportunity that we, you know, we think is worth it, we'll absolutely partner.
You know, most markets around the world we have to be careful about because they're still comparing to a generic. I think we need to have a little bit more under our belt in the U.S. and get some experience in some of these named patient countries. Then I think we'll go for it in those areas. We've been talking to a lot of partners, and I think everybody sort of agrees we're on the right track.
Great. Lastly, on 301, just wondering if you could comment on, let's assume that the phase I study reads out positively. What implications might this have for future broader utilization of RTGel, not just with a molecule like zalifrelimab, but with potential other monoclonal antibodies, and if there's any possible read-through that you could get from this context to not only the utilization of RTGel with molecules beyond zalifrelimab in the context of the genitourinary context, but also in potentially other areas of the body where RTGel's unique characteristics might be advantageous.
Yeah. You absolutely couldn't say it better myself. You're right. The work that we do in UGN-301 and combinations will be, you know, a testament to the ability to give local delivery, right, of medicines. I think that, you know, we do have many companies sort of watching to see what happens here. You know, urologists treat locally, and particularly these cancers. We're learning more about it. I'd like for Mark to sort of comment about some of the recent, you know, work that we've sort of uncovered. That, you know, local delivery especially, you know, in the bladder, you know, is definitely available. I mean, you know, there's definitely benefit to doing that. We believe to your point, specifically in urologic cancers, but even beyond that.
As you know, we've announced some work, you know, with some of the academia in other areas like head and neck and, you know, colorectal cancer. We do believe esophageal cancer. There are many other areas of the body in which our RTGel technology could work very nicely. But Mark, do you just wanna comment on what we're sort of finding out about local delivery, particularly immunotherapy?
Yeah. Thanks, Liz. Ram, this is a very interesting question and a hot topic for us. Look, I'll just say that we have lately appreciated through our own work and also understanding the work of some others in the area, that there may well be an accessible local immune system at the level of the epithelium, which would be very generalizable when you think about locally applied immunotherapy, which of course would be absolutely accessible to our platform in a way that could be clinically exceedingly meaningful for a variety of epithelial neoplasms. You know, not to gild the lily here, but everybody I'm sure appreciates that cancer is an epithelial disease for the most part.
The ability to interact with the immune system at the level of the epithelium in the context of cancer may be profound, and we are very interested in this topic and working on it hard right now.
Thank you very much.
Our next question comes from Matthew Kaplan with Ladenburg Thalmann.
Hi, good morning, and thanks for taking the questions. Just wanted to follow up on the nephrostomy tube administration, antegrade administration of Jelmyto. Currently, can you give us a sense in terms of what percentage of procedures use that? Help us think about the adoption of that route administration and how that impacts potential growth of Jelmyto going forward.
Sure.
Yeah.
Yeah, no. We haven't really commented on the number, but I will say this, is that it's higher than we expected, given that yes, it's in the label, but we really didn't have until Katie Murray's paper, we didn't have a lot of good data. As we continue to get more data, and go out and able to talk about that, publish it. The reps are equipped with resources that guide practices that are interested in this. I would just say that as more and more questions come in, more and more folks are administering the first dose retrograde, and then the following 5 in the clinic through a nephrostomy tube.
I do, as I said in the past, I expect this to continue to grow, and it will grow even faster as we can get out there with more data. But there is a significant interest, even physicians who said, you know, at launch two years ago, a year and a half ago, that they wouldn't consider this route of administration, have sort of changed their minds, changed their tunes, and they're open to it. The more discussions that are going on. The real advantage is to the patient, the convenience to the patient, and the practice. They can do this in their clinic. They don't have to schedule OR time.
Yes, there's certainly a lot of buzz and a lot of interest, and it's our goal is to get more data out there. I do see that growing significantly in 2022 as we do that.
Okay. That's helpful. Thank you. I guess question for Mark. Can you talk a little bit about the differences between ENVISION and the OPTIMA II study, that you think will increases probability of success then?
Thanks, Matt. The studies are really the same. We're targeting a relapsing low-grade intermediate risk population, which is exactly what we did in the phase II trial. I think, as I said earlier, I think that because the trials are, except for the size essentially, and the number of sites involved, essentially identical, I think the phase II does give very good preliminary guidance as to what we might expect in the ENVISION trial. It is the same group of people being treated, the same type of patient being treated in an identical manner. I think we'll have to see what the results look like, obviously, but we are optimistic that the phase II does give us a sense of what we would expect in phase III.
All right. Thank you for the added color.
I'm not showing any further questions at this time. I'd like to turn the call back to UroGen's President and CEO, Liz Barrett, for any closing remarks.
Great. Thank you. You know, as always, we appreciate your interest in UroGen, and you know we're building a very unique company. We're really proud of the progress that we've made. 2022 promises to be yet another eventful year, and we look forward to partnering with all of you to bring these patients better options. Operator, we can disconnect. Thanks again, everybody.
Ladies and gentlemen, you may now disconnect and have a wonderful day.