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A substantial increase in the number of elderly patients with muscle invasive bladder cancer (MIBC) is expected in upcoming years due to demographic changes and the peak incidence of bladder cancer in the 8th decade of life. The management of these patients is mainly driven by chronological age, comorbidities, tumor characteristics (unifocality, multifocality, concomitant carcinoma in situ, depth of invasion) and the presence of tumor-related symptoms (hematuria, pain, bladder dysfunction). A potential algorithm for the treatment of elderly patients with MIBC is presented. Ideally these patients are managed by a multidisciplinary team that includes an in-depth geriatric assessment and in centers experienced with MIBC to avoid any delay for—potentially—curative treatment.