Urothelial carcinoma, particularly CIS, is considered a field-change disease with the entire urothelium at risk in affected individuals. Clinicians should remain aware of sites outside the bladder as potential sources for metachronous tumors. While the initial diagnostic evaluation includes radiographic/endoscopic visualization of the entire urinary tract, the extra-vesical urothelium remains at long-term risk for subsequent tumor development. Moreover, these sites may harbor disease and contribute to cancer recurrence within the bladder. Indeed, tumor recurrence involves the prostatic urethra in 24-39% of patients with NMIBC.237, 238 Meanwhile, metachronous upper tract tumors are discovered in up to 25% of patients with NMIBC,238 and patients with more frequent bladder recurrences have an increased risk for upper tract tumor diagnosis.239 Further, a recent study of patients with high-risk non-muscle invasive disease failing two or more courses of BCG demonstrated upper tract and/or urethral carcinoma in over half of the cases during follow-up.240 It is important to note, however, that the overall risk for patients with bladder cancer to develop upper tract carcinoma is low (0.8% to 10%).241-243 Upper urinary tract imaging and prostatic urethral biopsy are warranted to assess potential tumor sites that may serve as a source for bladder recurrence in patients with persistent or recurrent disease after intravesical therapy. The technique for prostate urethra evaluation is at the discretion of the surgeon, with acceptable approaches including transurethral loop resection and cold-cup biopsy of the prostatic urethra at the 5- and 7-O’clock positions.84, 244 It is the Panel’s consensus that upper tract evaluation be performed with contrast-based imaging (i.e., CT or MR urography, intravenous pyelogram [IVP], or retrograde pyelogram). In addition, at the time of cystoscopic evaluation, bilateral selective ureteral cytology via washing may be obtained. Further diagnostic evaluation may then be undertaken pending the findings of these initial studies. Of note, the Panel recognizes that evaluation of the upper urinary tract and urethra may be withheld in select patients who have received a single induction course of intravesical BCG and subsequently have persistent evidence of disease and are to undergo a second course of BCG.