| Disease state at time of recurrence | Prior management | Second-line therapy | Third-line therapy |
| Intermediate risk (LG Ta) | TUR only | Surveillance, office fulguration, or TURBT | Same or intravesical therapy |
| Intravesical chemotherapy | Intravesical BCG | ||
| Intravesical BCG | Intravesical chemotherapy | ||
| Prior intravesical chemotherapy | Intravesical BCG | Clinical trial, other intravesical therapy, consider cystectomy only if unable to control disease | |
| Prior intravesical BCG, last dose ≤6 months | Intravesical chemotherapy | ||
| Prior intravesical BCG, last dose >6 months | Intravesical chemotherapy or BCG | Clinical trial, intravesical chemotherapy | |
| High risk (HG Ta, CIS) | TUR only | Intravesical BCG | Same as second-line post-BCG |
| Prior intravesical chemotherapy | Intravesical BCG | Cystectomy if recurrence within 6 months of last BCG dose, otherwise retreat with BCG; avoid more than 2 cycles of intravesical therapy if no interval response | |
| Prior intravesical BCG, last dose >6 months | Intravesical BCG | ||
| Prior intravesical BCG, last dose ≤6 months | Cystectomy most definitive with lowest risk of progression but risk of overtreatment; for patients with BCG-unresponsive CIS who are unfit for or decline radical cystectomy, options include systemic pembrolizumab, intravesical chemotherapy, or BCG plus IFN | Cystectomy | |
| Very high risk (HG T1) | TUR only | Intravesical BCG | Cystectomy |
| Prior intravesical chemotherapy | Immediate cystectomy or BCG | ||
| Prior intravesical BCG, last dose >6 months | Immediate cystectomy or BCG | ||
| Prior intravesical BCG, last dose ≤6 months | Cystectomy |
