In the United States, local management of muscle-invasive bladder cancer largely remains radical cystectomy with urinary diversion. However, this approach is undergoing transition. Organ-preserving approaches using a combination of multiple modalities have been successfully applied to the management of several types of cancer and clearly play an important role in the management of muscle-invasive bladder cancer as well. Since the 1980s, several single and multi-institutional trials have confirmed that a combined modality organ-preserving approach (chemotherapy administered in conjunction with radiation) consistently confers equivalent overall survival compared with survival following radical cystectomy. These trials are very encouraging and allow organ preservation to be considered an appropriate therapeutic option for patients with muscle-invasive bladder cancer.