The optimal treatment of T1G3 bladder cancer remains controversial. These tumors have a high propensity to recur, progress, invade and metastasize. While bladder preservation by transurethral resection followed by intravesical bacillus Calmette-Guerin is possible in some cases, studies with long term follow-up periods has documented that survival is compromised due to tumor progression in a substantial percentage of patients with T1G3 tumors. Although radical cystectomy for T1G3 disease is associated with an excellent survival, the optimal timing of radical cystectomy remains a dilemma for T1G3 disease. This article reviews the possible factors associated with an increased risk of tumor progression and provides recommendations for early radical cystectomy for T1G3 tumors.