FIG. 36:  If there is a recurrence is at 3 months, we follow the chart in the Figure on the left side (“Yes”).  If this is CIS at 3 months, as I discussed earlier, we can continue BCG therapy – that is the first maintenance course – and evaluate the patient at 6 months.  If this is a Ta high-grade lesion, we should discuss the option of radical cystectomy.  One may consider continuing BCG therapy and close re-evaluation at 6 months.  If these patients are T1 high-grade, they should be considered BCG-unresponsive.  For these BCG-unresponsive patients, radical cystectomy is the only recommended option.  If the patient refuses a radical cystectomy, one may consider a clinical trial, and if a clinical trial is not available or is denied, one may consider therapies that are being developed or have been published, such as enhanced mitomycin or off-label use of intravesical chemotherapy. 

If this recurrence is not at 3 months (right side of the Figure), then we need to assess whether the patient has received adequate BCG therapy.  In other words, did the patient get ≥1 courses of BCG maintenance?  If the answer is yes and the exposure was ≤6 months, then this patient is BCG-unresponsive and follows that pathway.  If the patient has not received BCG maintenance therapy, then one may consider repeating induction if >1 year has elapsed, or start maintenance therapy if <12 months has elapsed since the last BCG exposure.  Of course, if this patient has another recurrence, then it is important to recognize the timing of recurrence and if the patient has early recurrence, or even intermediate recurrence, we should consider radical cystectomy or alternative intravesical therapy.  If these patients have a late recurrence, they may go on to consider repeat induction BCG.