Four hundred twenty-one patients with bladder carcinoma were treated with radical intent between 1968 and 1981: 356 were treated with irradiation alone with megavoltage tumor doses of 60-66 Gy delivered over a period of 6 to 7 weeks. Actuarial 5and 10-year survival was 66% and 58% for Stage A (58 patients), 42% and 35% for Stage B1 (62 patients), 35% and 28% for Stage B2 (120 patients), and 23% and 19% for Stage C (75 patients), respectively. Five-year survival after salvage cystectomy (47 patients) was 51% from the time of surgery, with 4 operative mortalities and a major complication rate of 30%. Sixty-five patients were entered into an integrated preradical cystectomy irradiation program. Fifty-three patients in stages BI-C-DI received high-dose preoperative radiotherapy (40-50 Cy) before a planned, delayed radical cystectomy. The actuarial 5-year survival was 66% for 65 patients, and 64% for the 53 patients in the high-dose precystectomy program; major complications were encountered in 34% and there were 2 mortalities. Five-year actuarial survival for Stage B2-C was 30% but fell to 24% when patients with salvage cystectomy were excluded. Distant metastasis was found in 30% of patients in Stage BI-C-DI, and also in the high-dose precystectomy program patients. Two-thirds of patients with distant metastasis in the radiation alone group were never considered for salvage cystectomy as they had distant metastasis alone, persistent disease with metastasis within 6 months after initiation of irradiation, or local recurrence and distant metastasis simultaneously. Early local recurrence may be salvaged in 50% to 60% of patients without a significant increase in mortality or major complications. Accordingly, a program of radical irradiation with salvage cystectomy may avoid loss of the bladder in 45% of patients in Stage B2-C-DI without compromising overall survival.