There is an underutilization of potentially curative treatments for patients with muscle-invasive bladder cancer (MIBC), especially in the elderly. Contemporary trimodality bladder-preservation therapy – which includes a maximally safe transurethral resection of the bladder tumor followed by concurrent chemoradiation and close cystoscopic surveillance with salvage cystectomy reserved for invasive tumor recurrence in surgical candidates – may fulfill this unmet need. Over the past 3 decades, cumulative published data from prospective clinical trials and large institutional series have established bladder-preservation therapy for select patients as a safe and effective alternative to immediate cystectomy. Trimodality therapy has demonstrated excellent local control and 5-year overall survival rates of 48-65%, comparable to those reported in cystectomy studies. Over 70% of long-term survivors maintain their native bladders, which tend to function well with relatively low rates of long-term toxicity. Salvage cystectomy for patients who develop a local invasive recurrence can be performed with acceptable operative complication rates. The contribution of selective bladder-sparing therapy to the quality of life of patients represents a unique opportunity for urologic surgeons, radiation oncologists and medical oncologists to work hand-in-hand in a multidisciplinary effort. In the future, biomarkers may allow improved selection of patients most likely to succeed with trimodality bladder-preservation therapy.