<p>Radical cystectomy (RC) with pelvic lymphadenectomy followed by urinary diversion is the standard treatment for muscle-invasive bladder cancer (MIBC). Perioperative systemic therapy can improve the oncological outcome of RC. Despite the use of modern surgical techniques, RC is still associated with a&#xa0;high rate of perioperative complications and reduced quality of life. As an alternative to RC, organ preserving trimodal therapy can be performed in selected patients. In light of newer and more effective systemic therapies and the associated higher response rates to neoadjuvant systemic therapy, interest in novel organ-preserving concepts for appropriate patients with MIBC has increased. These approaches aim to better preserve quality of life while achieving oncological outcomes that are at least comparable to those of RC. Clinical re-evaluation after initial systemic therapy requires establishment of robust surrogate parameters for complete pathological and systemic response. To this end, existing combined restaging methods (transurethral resection of bladder tumor [TUR-BT], urinary diagnostics, imaging techniques, liquid biopsies) need to be further developed and validated. This narrative review outlines current developments and challenges that must be considered for the successful implementation of organ-preserving approaches in MIBC and defines the prerequisites under which organ preservation may be feasible.</p>