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Over a median follow-up of 15.2 months, there was a recurrence rate of 52% in patients who received gemcitabine vs 87.5% in those patients who received further BCG. This equated to a statistically significant difference in recurrence-free survival at 2 years (P http://www.selleckchem.com/products/VX-770.html and distribution might be improved by heat, as well as enhanced drug metabolism and DNA reaction. Heat may also damage DNA repair and vasodilatation in areas of tumour neovascularisation and might lead to an amplified effect of heating within the tumour tissue relative to surrounding normal bladder [52]. Van der Heijden et?al. [53] studied thermo-chemotherapy in 90 patients with intermediate- and high-risk NMIBC. Within the study, there was a subset of 41 patients who had failed BCG, and about half of those patients remained recurrence free at a http://www.selleckchem.com/products/ch5424802.html median follow-up of 27 months. A further 51 patient multi-centre study (European Synergo? working party) used weekly outpatient thermo-chemotherapy to treat CIS, with a duration of therapy http://www.selleck.cn/products/Verteporfin(Visudyne).html of between 6 and 8 weeks. Within this series, a subset of 34 patients had previously failed BCG and these patients had a 92% complete response with durability in about half of the cases at 2 years [54]. Finally, Nativ et?al. [55] studied 111 patients with BCG-refractory disease with a similar treatment protocol. Overall, 85% were disease free at 1 year with 56% remaining disease free at 2 years. Collectively, these series suggest a role for thermo-chemotherapy in BCG salvage and some groups have begun to use MMC thermo-chemotherapy first-line in patients with high-risk NMIBC who fail BCG therapy. In a recent series of 61 patients treated with thermo-chemotherapy after BCG failure since 2006, 73% are currently free of disease and have not required cystectomy or radiotherapy [56]. This treatment is unavailable in Australia or New Zealand. Photodynamic therapy has been used to salvage BCG failure in two small phase I trials, with some success in preventing progression and/or recurrence [57, 58]. Although the patient numbers are inadequate, the response and durability looks to be mediocre. Moreover, patients may experience photosensitivity, mucosal sloughing, bladder contractures and/or hypotension on administration of the photosensitising agent [57-59]. Intravesical therapy retains a critical role in the management of NMIBC.