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Bladder cancer is a highly prevalent disease in the Western World, and the treatment paradigm is actively evolving. For decades, the most commonly used standard of care for localized muscle-invasive disease has been neoadjuvant chemotherapy followed by open radical cystectomy with urinary diversion. Considering the high postoperative morbidity of this procedure, efforts have focused on improving patient outcomes. Over the past decade, substantial advances have been introduced in imaging, prehabilitation, perioperative care, robotic surgery and organ-sparing techniques. Bladder preservation after complete clinical response to neoadjuvant treatment or after trimodal treatment is increasingly being implemented. In addition, novel biomarkers are increasingly being used to monitor treatment response and select patients for adequate therapy. Last, innovative approaches, such as intraoperative imaging, sentinel lymph-node biopsy or the use of artificial intelligence, are currently under investigation.