Bladder cancer represents a major challenge to the oncologist. In spite of new tech niques for early diagnosis and innovative imaging procedures for staging, the outcome in terms of cure has not improved during the past ten years. Fortunately, about 74% of the patients present with localized disease, with 18% presenting with localized and regional disease, and 3% with distant metastases at diagnosis. In accordance with the stage at presentation, 94% of patients with localized disease are controlled at 5 years, as are 50% of patients with local and regional disease but un fortunately only 7% of those with distant disease. The survival data for Afro-Americans are more grave, with only 79% of patients with localized disease surviving at 5 years, 38% with local and regional disease, and 4% with disseminated disease. Even after 5 years, however, patients continue to fail not only locally and regionally but also with disseminated disease, thereby creating enigmas as to the continued influence of basic molecular changes, basic etiologic agents, and unsuspected more advanced disease, as well as demonstrating the inadequacies of local surgical treatment programs. These factors have led to braoder programs of combined integrated multimodal treatment earlier in the course of the disease process. Clearly, these newer innovative programs have placed increasing emphasis on the combination of surgery with radiation therapy and chemotherapy.