Radical cystectomy (RC) is the standard treatment for localized muscle-invasive bladder cancer (MIBC) in most Western countries. Historically, a delay of 12 weeks between the diagnosis of an MIBC and radical cystectomy performance has been associated with worse outcomes. Neoadjuvant chemotherapy should be initiated as soon as possible, i.e., no more than 8 weeks, to prevent upstaging. In recent years, laparoscopic and robotic approaches to RC have gained interest compared to the standard open approach. These approaches have been reported to be not inferior to the open approach with regard to perioperative and oncological outcomes. For both techniques, surgeons’ experience and institutional volume are strongly associated with outcomes. Different approaches have been described to improve voiding and sexual function in patients undergoing RC for bladder cancer (BC). No consensus exists on which approach preserves function best. Concern remains regarding the impact of “sparing techniques” on oncological outcomes. In men, standard RC includes removal of the bladder, prostate, seminal vesicles, distal ureters, and regional lymph nodes (LNs). In women, standard RC includes removal of the bladder, entire urethra and adjacent vagina, uterus, distal ureters, and regional LNs.