The likelihood of detecting CIS on random bladder biopsies in patients with low-risk disease is exceedingly small but increases significantly in patients with high-risk disease or positive cytology.75, 76 For such patients with a positive cytology and negative cystoscopy, surgeons should consider use of fluorescence-guided cystoscopy to evaluate the bladder. Indeed, BLC has been demonstrated to increase the detection of CIS by 20-40%66, 77, 78 and has been demonstrated to be of benefit in additional tumor detection, specifically among patients with a positive cytology and negative white light cystoscopy (WLC).79, 80 Nevertheless, the Panel acknowledges that the value of BLC has not been directly tested to date versus random bladder biopsies in this setting and that the false-positive rate of BLC may be increased in patients recently treated with BCG.77, 78, 81 Although bladder cancer represents the most common source for a positive voided urine cytology,82 both the upper urinary tract and the prostatic urethra should be evaluated for tumor recurrence in patients with a persistently positive cytology after intravesical therapy in the absence of demonstrated disease in the bladder. In particular, the Panel supports investigation of the upper tract and urethra prior to further bladder-directed therapies for patients with a positive cytology and no evidence of concurrent disease in the bladder. Involvement of the prostatic urethra is very uncommon in men with low-risk disease but increases substantially in the presence of CIS, multifocal disease, and tumors of the bladder neck and trigone.34, 83 Approximately 20% of patients with a positive cytology but no visible bladder tumors after a complete BCG response have urethral recurrence.84 Upper tract evaluation can include CT urography, retrograde pyelography with or without upper tract selective cytology, and/or ureteroscopy depending on the degree of clinical suspicion for upper tract involvement.85