Muscle invasive, but still locally confined bladder cancer is treated by radical cystectomy in most of the patients. New forms of bladder substitution and operative techniques provide good quality of life; however, any kind of bladder substitution is suboptimal to a well-functioning and disease-free bladder. Bladder preservation in muscle invasive cancer is only possible in a selected group of patients by transurethral resection, partial cystectomy or definitive radiotherapy. The introduction of effective systemic chemotherapy made integrated therapy strategies attractive. The results in terms of complete remission are significantly improved over monotherapeutic approaches, but recurrent tumors within the bladder still occur in a similar percentage. This fact indicates that only appropriate selection of patients with a low risk of recurrence, and additional local adjuvant therapy may lead organ-preserving therapy modalities to the point where it is a true alternative to radical cystectomy.