The standard treatment for muscle-invading bladder tumors is, in the US, radical cystectomy +/- radiation; in Europe, it is radical radiotherapy. Neither of these therapies alone is wholly satisfactory. Suggested improvements in the complete response rates of the primary tumor have been reported with combination chemotherapy and with chemo-radiotherapy. Selecting for full chemo-radiotherapy only patients having a biopsy-proven CR to initial chemotherapy and/or to 4,000-4,500 cGy of radiation may further increase the success of bladder-preserving programs and not compromise survival (relative to immediate cystectomy), but this has not yet been proven. Randomized trials of neoadjuvant chemotherapy must be finished before its efficacy in subclinical systemic disease will be known. Likewise, proof of the efficacy of neoadjuvant chemotherapy in improving bladder preservation by chemo-radiotherapy must await completion of randomized trials. Three to five years of follow-up will be necessary before chemo-radiotherapy can be recommended as curing the bladder of cancer.