Background: Localized muscle invasive bladder cancer carries a significant recurrence and mortality rate. The purpose of this study was to compare 5-year overall survival (OS) of neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC), RC alone, bladder preserving chemoradiotherapy (BPCRT) and radiation alone (RT) on selected histologies. Methods: We sampled the National Cancer Database (NCDB) for bladder cancer patients diagnosed with AJCC 7th Stage 2 and 3 for urothelial carcinoma (UC) including variant histologies, squamous cell carcinoma (SCC) and adenocarcinoma (AC) from 2004-2018 with definitive intent treatment. 5-year Kaplan-Meier survival plots were utilized to assess survival differences amongst treatment modalities and stratified by selected histologies. Multivariate cox regression models were used to compare hazard ratios and logistic regression analysis was performed for covariate analysis. A p-value <0.05 was considered statistically significant. Results: A total of 20,629 patients met inclusion criteria. The average age was 69.51 + 11.02 years, 68% were male. UC represented 94.1% of selected histologies, followed by 4.6% SCC and 1.3% AC. For all combined histologies, 5-year OS for patients with NAC followed by RC was 58%, 48% for RC alone, 33% for BPCRT and 10% for RT alone. RC alone provided a longer OS in the SCC and AC groups, 48% and 47% respectively (p<0.001). NAC followed by RC showed superior OS in the UC group (58%, p<0.001), with OS decreasing to 43% in SCC and 44% in AC. BPCRT showed lower 5-year OS in all selected histologies when compared to NAC followed by RC and RC alone (33% in UC, 27% in SCC and 24% in AC group). In all selected histologies, RT showed the lowest 5-year OS (10% in UC, 8% in SCC and 17% in AC group; p<0.001). Furthermore, covariables associated with lower 5-year survival were male sex (p<0.001) and TNM Stage 3 (p<0.001). Conclusions: NAC followed by RC showed improved 5-year OS for UC. The benefit of NAC was marginal for SCC and AC histology. RC is better than BPCRT for all histologies. RT alone showed inferior 5-year OS for all histologies.