Abstract Objective Is there a role for intravesical chemotherapy in a patient who has a first recurrence of a T1G3 bladder cancer? Materials and Methods American and European guidelines are checked for their advise, and recent literature on this topic is reviewed to critically test the advice and look for potential alternative strategies in this particular case. Results Guidelines indicate that a patient with a pT1G3 tumor should initially receive BCG intravescial therapy, although cystectomy can be considered. In case of a recurrence, cystectomy is the treatment of choice. Although several new drugs and strategies are under development and in clinical research, there is only experience to some degree in BCG failing patients with thermochemotherapy, with promising results. Conclusions In a patient with a recurrence of T1G3 bladder cancer after BCG therapy, progression and subsequent cancer death is the threat. Guideline standard is radical surgery. Alternative possibilities are still limited.