Background: Trimodality bladder preservation is an acceptable alternative to radical cystectomy (RC) for muscle invasive bladder cancer (MIBC). Multiple retrospective studies have reported similar disease control rates and overall survival rates with chemoradiation (CRT), but the benefit of neoadjuvant chemotherapy (NAC) prior to CRT is not established. This study investigates the outcomes of CRT with or without NAC for management of MIBC. Methods: Retrospective analysis of 135 adult patients with muscle invasive bladder cancer evaluated in the Department of Radiation Oncology over 7 years (2016-2022). Patients were excluded if they did not receive NAC or if they underwent RC. Patients were treated with NAC followed by CRT. Overall survival (OS), progression-free survival (PFS), and metastasis-free survival (MFS) were calculated using Kaplan-Meier methods. Follow-up was censored at 36 months after treatment. Differences in survival outcomes by completion of status of NAC were analyzed using log-rank tests. All survival analyses were performed in SAS version 9.4. Results: Of the 135 evaluated patients, 38 were treated with NAC followed by CRT. The 24-month OS, PFS, and MFS were 76% [95% CI 62-92%], 60% [95% CI 46-79%], and 72% [95% CI 58-90%] respectively. The 24-month PFS in patients who received a full course of NAC was 66.0% [95% CI 50-87%]) and 38.0% [95 CI 15-92%] in those who did not complete NAC regimen. Overall PFS was significantly higher in the NAC cohort (log-rank p=0.03). There was no significant difference in OS between patients who completed prescribed course of NAC versus those who did not (log-rank p=0.48). Treatment was overall well tolerated with 28.2% of grade 2 or higher RT toxicity. Conclusions: NAC prior to CRT achieved excellent short term disease-free and survival outcomes in patients with non-metastatic MIBC. This analysis is limited by its retrospective nature but suggests that completion of NAC prior to CRT may be associated with lower rates of disease recurrence.