Background: Cisplatin ineligibility in metastatic urinary bladder cancer patients poses a major therapeutic challenge. The reported incidence was approximately 20-30% of metastatic urinary bladder cancer. In the absence of insurance, "the immunotherapy" can be economically draining at the current cost. Moreover, there are patients in whom immunotherapy might not be feasible due to comorbid conditions. Therefore, there persists a need to optimize chemotherapy options for gemcitabine combination with either Paclitaxel or Carboplatin are recommended chemotherapy options. However, limited prospective studies are comparing the two options. Methods: This was a non-funded, prospective, randomized, single-center study among treatment naïve cisplatin-ineligible metastatic urothelial cancer from a tertiary care institute from India. The study enrollment duration was 18 months. Patients were randomized in one of the two treatment arms. The "Arm A" received (Gemcitabine and Carboplatin) and "Arm B" received the (Gemcitabine and Paclitaxel) combination chemotherapy, respectively. The two treatment arms were compared prospectively for disease control, survival, and adverse events in an Intention to treat analysis. Results: A total of 32 eligible participants were randomized in the study. "Arm A" vs. "Arm B" had an 18.7% vs. 25% drops out rate, respectively. The ORR was 40% vs. 88.4%; median PFS and OS were 3.7 vs. 3.8 months and 7.3 vs. 14.0 months, respectively. The serious adverse events were nonoverlapping. Hospitalization was needed for the care of adverse events among 37.5% vs. 12.5% patients, respectively. Conclusions: Both groups reported that similar PFS. However, better ORR, OS (though not statically significant), and lower hospitalizations for adverse event management favor the Gemcitabine with paclitaxel combination over Gemcitabine with Carboplatin. Clinical trial information: CTRI/2020/02/023402.