FIG. 41:  This Figure lists the criteria that I use to determine whether a patient can be safely treated initially with BCG.  (These criteria must also take into consideration the patient's age and general health and the risk of radical cystectomy and its side effects, of course.) 

• Number one: No persistent disease on restaging TUR. In exceptional cases, I will do a third TUR to get rid of the T1 if the initial TUR was not done by me or was not complete for some other reason. 
• Number two: If there is prostatic stromal invasion, obviously the patient’s carcinoma is not a T1 anymore. But CIS in a ductal area is certainly considered a high-risk disease that has a low likelihood of responding to BCG. 
• Number three: I would prefer that the patient not have lymphovascular invasion.
• Number four: The patient and his bladder need to also be taken into consideration. If the patient has a lot of irritative voiding symptoms, he often is best treated with radical cystectomy.  These cases are, however, very rare. 
• Number five: I would insist on the absence of micropapillary, sarcomatoid, or plasmacytoid variants. While the data are not mature enough to be included in the guidelines as a clear recommendation, I believe will mature over time. 
• Number six: The tumor must be able to be completely resected. None of the adjuvant treatments is effective in an unresected tumor, and large multifocal tumors seem to be difficult to be completely resected. 
• Number seven: The patient must be compliant. Strict long-term follow-up is necessary, and just to forgo a radical cystectomy and be treated with BCG does not mean that this strategy has to prevail. 
• Number eight: One needs to be ready to change strategy. If early treatment failure is apparent a prompt radical cystectomy needs to be considered.  The option of radical cystectomy needs to be discussed with the patient early on as an alternative, especially in patients with high-risk, aggressive features. 
• Number nine: As a physician and a patient advocate, smoking cessation consultation needs to take place early on.