Background: Radical cystectomy is an underutilized option for those with refractory non-muscle invasive and muscle-invasive bladder cancer, however, use of radical cystectomy may differ according to gender. We wanted to discern receipt and timing of radical cystectomy as well as survival outcomes according to gender. Methods: A total of 49,974 patients aged 66 years or older diagnosed with clinical stage I-IV bladder cancer from January 1, 2002 to December 31, 2011 using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data. We used univariate and multivariable regression analyses to identify factors predicting the use of radical cystectomy. Cox proportional hazards models were used to analyze survival outcomes. Generalized linear models were performed to determine association between gender and delayed radical cystectomy. Results: A total of 49,974 patients were diagnosed with stage I to IV bladder cancer. 36,959 (74%) were male patients. Women were older, non-Caucasian race/ethnicity, with increased comorbidities and presented with more advanced disease (all p<0.001). Women were more likely than men to receive radical cystectomy across all clinical stages (stage I, relative risk [RR] 1.53, 95% confidence interval [CI] 1.27-1.84, p<0.001; stage II, RR 1.52, 95% CI 1.37-1.70, p<0.001; stage III, RR 1.26, 95% CI 1.15-1.39, p<0.001; stage IV, RR 1.31, 95% CI 1.17-1.47, p<0.001). Women had lower cancer-specific survival with stage II (hazard ratio [HR] 1.20, 95% CI 1.09-1.32, p<0.001), stage III (HR 1.44, 95% CI 1.23-1.68, p<0.001), and stage IV (HR 1.29, 95%CI 1.17-1.43, p<0.001) disease. Delay from diagnosis to radical cystectomy was associated with worse survival. Conclusions: Gender differences persist with women significantly more likely to undergo radical cystectomy independent of clinical stage. After controlling for tumor characteristics and neoadjuvant chemotherapy, women have significantly worse cancer-specific survival than men. Delay to surgery did not account for this decreased survival among women. These findings support further research discerning bladder carcinogenesis according to gender.