<p>With the success of perioperative systemic therapies in nonmetastatic muscle-invasive bladder cancer (MIBC), particularly with reported pathological complete response rates of up to 60%, bladder-preserving treatment strategies with the potential omission of radical cystectomy are increasingly coming into focus. However, there is currently no sufficient prospective randomized evidence to conclusively demonstrate oncological equivalence between bladder-preserving approaches and radical cystectomy. At the same time, the morbidity associated with radical cystectomy has significantly decreased due to the implementation of enhanced recovery protocols, centralization in high-volume centers, and the increasing adoption of minimally invasive surgical techniques. Recent data further suggest that quality of life following radical cystectomy is comparable—and in several domains even superior—to that observed after bladder-preserving treatment strategies. Future studies should specifically investigate de-escalation strategies and incorporate, in addition to a&#xa0;well-defined cystectomy control arm, the serial assessment of circulating tumor DNA (ctDNA) and urinary tumor DNA (utDNA) with the aim of more precisely identifying the subgroup of patients in whom omission of radical cystectomy is possible without compromising oncological outcomes or quality of life. Until such data are available, radical cystectomy should remain the gold standard and a&#xa0;central component of curative treatment for MIBC and—with the exception of carefully selected individual cases—should not be routinely deferred in favor of bladder-preserving approaches.</p>