Radical radiotherapy as primary treatment for a MIBC has traditionally come second to cystectomy as the gold standard. Now for patients who are unfit and want bladder preservation, radiotherapy combined with chemotherapy (chemoradiation) is an attractive option. 360 patients were randomized to either chemoradiation or radiation alone with 2 years follow up. The locoregional disease free rate in chemoradiation was significantly better at 67% v 54% for radiation alone, which is a 12% absolute difference. The 2 year relapse rate was 18% chemoradiation v 32% radiation alone, and there was a trend to more need for cystectomy salvage in radiation alone group 17% v 11% chemoradiation. There was no difference in overall survival. Excluded were patients with inflammatory bowel disease or previous radiation to that area. 2/3 received 64 Gy and the rest 55 Gy. Chemotherapy was synchronous with fluorouracil and mitomycin C. Most had good performance states, T2 disease (85%), urothelial cancers, a complete TURBT in 57% and incomplete in 26%, median age 73, with 67% having no residual mass post TURBT. Any adverse event was more common in chemoradiation 36% v 27.5%, most commonly gastrointestinal.