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Advancements in the management of muscle-invasive bladder cancer have increasingly focused on strategies that balance oncologic control with preservation of quality of life. The therapeutic landscape for neoadjuvant therapy is rapidly evolving as immunotherapy and novel agents are integrated into systemic therapy regimens. The utility of tumor tissue, plasma, and urine biomarkers in selecting patients for bladder preservation remains uncertain and warrants further evaluation in prospective clinical trials before incorporation into routine clinical practice. Clinicians should consider both tumor-specific factors and patient-specific factors when engaging in shared decision-making.