The use of perioperative chemotherapy in muscle-invasive bladder cancer patients is widely debated. It has been used both to improve survival and as a strategy for bladder preservation. A retrospective meta-analysis of randomized studies of neoadjuvant and adjuvant chemotherapy has revealed a 5% improvement in survival with neoadjuvant cisplatin-based combination chemotherapy. Whether all patients should be treated with chemotherapy is, however, a much debated topic. The goal of bladder preservation is to achieve cancer survival equivalent to radical cystectomy while maintaining quality of life. A multidisciplinary approach with either neoadjuvant chemotherapy alone or in combination with radiation therapy (RT) has been advocated, but randomized trials have not compared this approach with cystectomy. There are serious problems with the interpretation of results from analyses of randomized adjuvant chemotherapy trials after cystectomy for pT3-pT4a and/or pN(+)M0 disease. A retrospective meta-analysis of randomized adjuvant chemotherapy trials is hampered due to small patient numbers and underpowered survival curves. The urologic oncology community should actively support recruitment to ongoing adjuvant chemotherapy trials in order to answer this important question.