The management of the primary tumour in muscle-invasive bladder cancer is determined more by geographical location than by firm evidence of the superiority of either surgery or radiotherapy over the other. Recent technological advances in both specialties may change their acceptability and efficacy, but as yet none has been fully evaluated. The effect of chemotherapy on primary tumour control may also influence management choices. There is a need to reexamine the merits of surgery and radiotherapy in the modern era.