Multimodal therapy for locally advanced bladder carcinoma is being pursued in a wide diversity of protocols at this same time. While a number of innovative approaches are being explored, neoadjuvant and adjuvant chemotherapy in conjunction with cystectomy remains the dominant approach. The M-VAC regimen has become the dominant combination for the treatment of advanced bladder cancer; its use in an adjunctive setting is a logical progression. Although it is capable of effecting a response in the primary bladder lesion in a high percentage of cases, it is still not known whether survival will be enhanced. The use of radiosensitizing cytotoxics in conjunction with neoadjuvant chemotherapy, when combined with external-beam radiotherapy, is a provocative new approach that attempts to achieve both bladder salvage and enhanced patient survival. Completion of well-designed randomized studies will be necessary to determine whether these therapeutic innovations will yield any clinical benefit.