Bladder cancer is a significant cause of morbidity and mortality. Promising results with organ preservation strategies using multimodality treatment over the last decade offers an option for bladder preservation in a significant proportion of patients who currently undergo cystectomy. The primary goal of the bladder-sparing approach remains optimal patient survival. A multidisciplinary approach involving urologists, radiation oncologists and medical oncologists will go a long way in improving the prognosis and quality of life of these patients. Progress in molecular characterization of bladder cancer and definition of new-targeted therapies will provide new opportunities to tailor treatment to the specific needs of the individual. Introduction of chemoprevention strategies in patients with dysplasia and recurrent transitional cell cancer may reduce the rate of late cystectomies. This will further improve the efficacy of bladder preserving strategies. Improved techniques in delivery of radiation therapy will lead to more dose escalation with little toxicity and will allow the addition of further chemotherapeutic drugs or an increase in the dose or duration of concurrent chemotherapy. Most likely the next round of large trials will define the role of synchronous chemo radiotherapy once the results from Phase III studies comparing them with radiotherapy alone are published. The use of cytotoxic drugs such as gemcitabine and taxanes synchronous with radiation remains experimental today but may be incorporated into refined treatment protocols in coming years.