(UroToday.com) Most patients newly diagnosed with bladder cancer have non-muscle invasive disease (NMIBC). For patients with intermediate or high-risk NMIBC and those with carcinoma in situ (CIS), adjuvant treatment with Bacillus Calmette Guerin (BCG) is guideline-recommended on the basis of proven benefits in disease recurrence. While BCG is efficacious, many patients eventually develop BCG-unresponsive disease. Despite guideline-concordant care, many patients with BCG-unresponsive NIMBC are at significant risk for recurrence and progression. For many years, there have been very limited options for these patients. Radical cystectomy has remained the gold standard even though numerous approaches including intravesical and systemic therapies have been investigated.