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On average 20–30% of patients with non muscle-invasive bladder cancer will subsequently develop muscle-invasive disease with approximately 50% of the patients already bearing occult regional or distant metastases at that time. Few interdisciplinary centres are demonstrating multimodality bladder sparing approaches as equally effective when compared with radical cystectomy for muscle-invasive bladder cancer.So far no investigation could demonstrate prospective controlled data on long-term oncologic and functional outcomes comparing bladder-conserving strategies with radical cystectomy. It is evident that multimodality treatment regimens including a thoroughly performed transurethral resection of the bladder tumour, external beam radiation therapy, and chemotherapy can produce an increased amount of total costs in addition to the prolonged hospitalization of the patient during a trimodality bladder sparing approach. Therefore, in addition to the long-term oncological and functional outcome, the high costs of this approach together with the need for a very close cooperation between clinical disciplines and a highly compliant patient have to be taken in consideration.Without prospective controlled trials evaluating the long-term oncological results and the health-related quality of life for the multimodality treatment regimen for muscle-invasive bladder cancer, the radical surgical approach should still be considered as the standard treatment. Multimodality bladder preserving strategies might be a therapeutic option for carefully selected patients.