Background: Management of muscle-invasive bladder cancer (MIBC) in elderly patients is issue of vital importance. The aim of the present study was to compare the oncological outcome of radical cystectomy to trimodality bladder preservation therapy. Methods: Between 1996 and 2013, we treated consecutive 419 patients with MIBC. Of these, we identified 44 patients with MIBC (cT2-4aN0M0) aged 80-84 years. We retrospectively reviewed the clinical charts of these patients. All patients received maximally safe transurethral resection of the bladder tumor before definitive therapy. The patients were categorized according to the treatment options into 2 cohorts; radical cystectomy cohort (RCx, n = 22), or radiotherapy with chemotherapy cohort (Trimodality, n = 22). All patients in trimodality cohort received at least 2 courses of gemcitabine plus carboplatin chemotherapy. Each patient was evaluated every 3-6 months by blood test, urine cytology, and computed tomography. Overall survival (OS), progression free survival (PFS) was estimated by Kaplan-Meier method. Multivariate analysis was used to identify independent factors to predict OS or PFS. Results: There were no significant differences in patient backgrounds between the groups, except for ECOG performance status (ECOG-PS), Charlson comorbidity index (CCI) and eligibility for cisplatin. The mean ECOG-PS, CCI and the number of cisplatin-unfit patients were significant higher in trimodality cohort (p = 0.001, p = 0.034, and p = 0.003, respectively). There were no significant differences in OS and PFS between the groups. On multivariate analysis, ECOG-PS >1 was the independent prognostic factors for OS and PFS. Conclusions: Trimodality bladder preservation therapy for MIBC in elderly patients is comparable to those who received radical cystectomy. For patients with MIBC who are non-cystectomy candidates, or select patients who are motivated to keep their native bladders, trimodality bladder preservation therapy should recognized as an effective alternative to radical cystectomy, and be considered.