All Guidelines and substantial literature recommend radical cystectomy for patients who are fit for surgery with high-risk urothelial cancer that persists or recurs despite adequate intravesical BCG therapy. Patients with early, high-risk recurrences after BCG therapy are at significant risk of progression, and salvage intravesical therapies have poor success rates. These patients should be offered radical cystectomy. In addition, a recent study demonstrated that patients with a low glomerular filtration rate (GFR), subtype histology, and tumor size >3 cm may have particularly poor outcomes if they do not respond to BCG and should be prioritized for consideration of cystectomy.100 Limited studies support that select patients will respond to second induction regimens, particularly with BCG, and repeat intravesical therapy seems most appropriate in patients with late recurrences (>1 year) after previous complete response to intravesical therapy.236, 247, 248 Recurrent, high-grade T1 tumors in patients after adjuvant induction BCG carry a poor prognosis.257 When radical cystectomy is performed for pathologic NMIBC, 5-year CSS is >80%.272-275 However, there is substantial risk of progression to muscle-invasion in these patients with reported adverse consequences of further intravesical therapy and delayed cystectomy.258 Similarly, patients with T1 recurrence after BCG treated with radical cystectomy had improved five-year CSS compared to patients with T1 recurrence after BCG managed with second-look TUR and further intravesical therapy.262 Interestingly, radical cystectomy patients who progress to muscle-invasive disease after initial management of NMIBC have decreased CSS compared to patients with de novo muscle-invasive disease.259-261 Only minimal data examines chemoradiation in management of high-risk NMIBC,276 but current trials are underway evaluating the role of radiation therapy in patients with recurrent, high-grade T1 disease after intravesical BCG. Finally, as discussed previously, the prospective CISTO trial demonstrated that selected patient-reported and health-related quality-of-life outcomes may be improved after cystectomy for recurrent high-grade NMIBC compared with bladder-sparing intravesical therapy.263