Bladder cancer is inherently a disease of the elderly with the highest incidence occurring in the eighth decade of life. Approximately a third of the 70,000 patients diagnosed with bladder cancer in the USA in 2009 will have presented with muscle-invasive bladder cancer (MIBC) requiring aggressive management. Left untreated, most patients with MIBC suffer significant morbidity and die of the disease within 2 years of the diagnosis. While radical cystectomy, the best treatment option for local control of bladder cancer, has been shown to be safe in the elderly, outcomes depend more heavily on the functional status of the patient than on chronologic age. The current literature suffers from a focus on chronologic age versus functional age in assessing outcomes, selection bias introduced by evaluating retrospective cohorts and limited data on outcomes of alternative treatment options in the elderly. In addition, a focus on disease-specific and overall survival leaves limited information regarding the quality of life of patients following aggressive management of MIBC. In this article, we review current issues regarding the definition of the elderly, summarize the reported literature on outcomes for elderly patients by treatment approach and discuss limitations and recommendations for the management of elderly patients with MIBC.