FIG. 40:  I have categorized patient diagnoses by poor risk factors and very poor risk factors. 

• If prostatic urethral involvement is present in any form, then I will consider immediate radical cystectomy in many if not all of these patients.^[53,54]
• If persistent T1 disease is present at re-TUR, then I will counsel the patient about the high likelihood of failing BCG therapy, even given optimally.
• If lymphovascular invasion is present, I will counsel that immediate radical cystectomy should take place in many of these patients, because of the high risk of spread already happening.^[55]
• Aggressive variant histologies suggest immediate radical cystectomy, or at least discussion about this with the patient, ensuring that they understand their disease.^[56]

Poor factors that will not lead to immediate radical cystectomy but that provide information indicating that it should be considered, especially if multiples of these factors are present, include the following.

• Recurrent multiple tumors, which have an aggressive biology. The larger the size, the more likely there will be residual disease and aggressive activity.
• Substaging is of high importance, but a difficulty with it lies with reproducibility and the pathologic evaluation of the specimen, although this will imrpove with en bloc resection. While there are many staging and substaging methods, the most consistent way of determining substaging that affects prognosis seems to be the one assessing whether there is microinvasive T1 versus extensive T1 disease.^[57]  This can be determined in all patients and it stratifies the patients significantly.  This is information that helps determine the risk of disease progression and metastases, and therefore whether to proceed to early radical cystectomy. 
• Another factor is whether the bladder has CIS; here the main question is whether the disease is focal or diffuse CIS. If diffuse, the likelihood of failing BCG is >60%.