Background: Demographic changes account for an increasingly large proportion of elderly patients with urothelial carcinoma of the bladder. It remains under debate to which extent a patient might benefit from major surgery such as the radical cystectomy. Current tools for preoperative assessment of biological age might be of limited significance. The frailty concept, which refers to a biological syndrome of decreased reserve to stressors and resistance to stressors, has gained recent recognition for measuring patient’s physiological reserve and has been linked to adverse outcomes after surgery. Methods: Clinical, surgical and pathological data of patients undergoing radical cystectomy and lymph node dissection at Hannover Medical School with a minimum age of 60 years were retrospectively collected from 2000 to 2010. Frailty was assessed using the clinical frailty scale by Rockwood et al. derived from the Canadian Study of Health and Aging (CSHA). The relationship between frailty and various risk assessment tools such as the ASA-score, Charlson Comorbidity Index (CCI) and Karnofsky score (KS) in regard of long-term follow-up data was analyzed. Results: Our cohort included 255 patients (male 197, female 58). Mean age was 70 years (SD ±6.14). Patients were categorized into “not frail” (n=53, 21%), “vulnerable and mildly frail” (n=156, 61%), and “moderately/severely frail” (n=46, 18%). Higher CSHA was associated with increased CCI and higher rate of perioperative complications (each p<0.001). 179 (70%) patients had died during follow-up (mean follow-up, 61 months). Median survival differed significantly between groups (68 vs. 29 vs. 12 months, p<0.0001). In univariate analyses ASA, CCI, KI, and CSHA correlated with long-term survival (each p<0.001). In multivariate analysis only CSHA remained predictor of survival besides age, lymph node involvement, resection margins, and T-stage. Conclusions: The clinical frailty scale is an easy to use tool. It correlates with survival and perioperative complications after radical cystectomy. This study warrants further assessment of the frailty concept; however, it still has to be determined whether the clinical frailty scale is superior to other frailty assessment schemes.