(UroToday.com) Neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) are standard of care for patients with muscle-invasive bladder cancer (MIBC). Despite level 1 evidence, and many guideline recommendations, supporting this approach, it is relatively underutilized in part due to the high patient burden from systemic toxicity and postoperative complications. Due to comorbidity or the toxicity of treatment, many patients are either ineligible or unwilling to receive this treatment approach. As a result, up to 60% of patients with MIBC may not receive definitive therapy for MIBC.