Bladder cancer is a heterogeneous disease that carries a significant risk of progression and lethality. Radical cystectomy with pelvic lymph node dissection remains the predominant treatment for patients with muscle-invasive disease and offers the best chance of long-term disease control. However, radical surgery is insufficient in patients with advanced-stage disease. Current staging techniques are limited in their ability to detect extravesical disease and lymph node metastases. Thus, integration of systemic therapy with surgery to potentially eradicate micrometastases provides survival superior to that with surgery alone. Yet, because bladder cancer is typically a disease that affects an elderly population of patients with multiple comorbidities, there is a need for less invasive and bladder-conserving therapies. Some physicians have attempted to minimize morbidity by pursuing minimally invasive surgical techniques; however, the long-term effectiveness of this approach remains unproven. Trimodality therapy could be considered in patients with favorable disease status, and may be offered as a reasonable alternative, but does not replace standard treatments for patients with more aggressive disease. Consequently, further improvements in outcomes will rely on improved patient selection based on clinical and molecular assessments.