An improved quality of life secondary to reduced chemotherapy toxicity is an important end point in the treatment of all patients with metastatic cancer. In this review, we have demonstrated that gemcitabine and gemcitabine/cisplatin combinations appear to have a reduced toxicity profile compared with MVAC. Phase II studies with gemcitabine and cisplatin have shown good response rates that are possibly equivalent to MVAC, and a Phase III trial is now completed. Similar data have been reported for the paclitaxel/carboplatin combination and a Phase III trial comparing that combination with MVAC is planned. For patients with TCC who are in mild renal failure or who have significant underlying medical conditions, gemcitabine can also be considered as a reasonable single agent therapy. Complete responses can be seen, even in patients who are older than the age of 70. Moore et al., for example, demonstrated near complete responses to gemcitabine monotherapy in 4 patients older than 80 years of age. In conclusion, chemotherapy options for patients with metastatic bladder cancer have changed significantly with the addition of gemcitabine and other drugs to the armentarium. The integration of gemcitabine into the initial chemotherapy plan for these patients is still being developed. It is clear that this agent should be included in the management discussions of all patients with metastatic bladder cancer.