The diagnosis of non-muscle-invasive bladder cancer (NMIBC) consists of a wide spectrum, including low, intermediate and high-risk groups. The descriptions of these risk groups are based on "The European Organisation for Research and Treatment of Cancer" (EORTC) risk tables. These tables provide the probabilities of recurrence and especially progression. Recently, an additional "very-high-risk" subgroup has been defined. It is reasonable to propose immediate radical cystectomy to the patients with very-high risk NMIBC. If the patient refuses the surgery or is not eligible for the surgery due to the co-mobidities, bladder preserving strategies might be considered. We aimed to review the risk assessment for the evaluation of very-high risk NMIBC, and results and complication rates of recommended treatment modalities in this special group of patients.