• Alternative treatment in patients unfit for or opposed to radical surgery or for local palliative treatment inpatients with metastatic disease
• Preoperative radiation therapy (RT) prior to cystectomy may be considered in patients with invasive tumors 
• May consider adjuvant pelvic irradiation for patients with pT3/pT4 pN0-2 disease who recently underwent radical cystectomy with ileal conduit
• May consider intraoperative RT in highly selected T4b cases
• Intraoperative RT may be considered in patients with tumors extending to the abdominal and/or pelvic wall 
• Palliative RT combined with radiosensitizing chemotherapy is recommended especially in patients with metastasis or disease recurrence
• Recommended dose: 1.8-2.0 Gy daily fractionation
  • Conventional or accelerated hyperfractionation of 39.6–50.4 Gy may be applied to the whole bladder with or without pelvic nodal irradiation
• Absence of hydronephrosis and extensive CIS is a factor for positive treatment response

 Chemoradiotherapy

• For muscle invasive bladder cancer, radical radiotherapy is given using a radiosensitizer (eg Mitomycin + Fluorouracil or Cisplatin plus Fluorouracil or Cisplatin plus Paclitaxel or Cisplatin alone)
  • Low-dose Gemcitabine may also be considered
• Conventional fractional radiation therapy with a radiosensitizer may be used as palliative therapy in patients with advanced or metastatic disease
  • Recommended regimens include Cisplatin (preferred), taxanes (Docetaxel, Paclitaxel), Fluorouracil monotherapy, Fluorouracil + Mitomycin, low-dose Gemcitabine, or Capecitabine monotherapy
• Concurrent chemoradiotherapy is an alternative option to radical cystectomy in patients with recurrent Ta-T1 disease (without extensive Tis) with history of BCG therapy and ineligible for cystectomy
  • Also recommended for patients in need of added tumor cytotoxicity