As the life expectancy of Japanese population has been increasing, how best to treat invasive bladder cancer in elderly patients has become a new problem. Generally standard treatment for locally advanced invasive bladder cancer is thought to be radical cystectomy, but that for elderly patients is still controversial due to frequent presence of comorbid diseases. Here, we debate the merits and demerits of radical cystectomy and bladder preservation for elderly patients with locally advanced invasive bladder cancer. First, we presented the treatment outcome of 1131 patients with invasive bladder cancer who underwent radical cystectomy in Japan, to clarify the characteristics of invasive bladder cancer of elderly patients and to determine whether age had an impact on the clinical or functional results. Furthermore, to clarify the indication of the bladder preservation for elderly patients, we reviewed the results of recent trials. Several new trials of chemoradiotherapy have shown high response rates with low local morbidity but high systemic morbidity requiring dose reductions or treatment delay. This regimen may prove to be effective for inoperable patients and may be proposed as conservative treatment for patients with complete responses to the initial course of chemoradiation. Although chemoradiation shows promise, more trials are needed to clarify the morbidity and mortality rates of chemoradiation for elderly patients.