Primary treatment of bladder cancer is radical cystectomy and pelvic lymph node dissection. Pathological stage is the major prognostic factor for overall survival after surgery. Ten years' disease free survival of the patients with cancer confined to bladder and no lymph node metastases is 73% whereas it is 22-33% in those with extravesical disease (T3-T4) or lymph node metastases. Therefore local treatment alone is insufficient in these high risk patients and systemic adjunctive therapy is needed. Bladder cancer is relatively chemosensitive. The efficacy of chemotherapy was previously demonstrated both in advanced and neoadjuvant setting. However adjuvant chemotherapy in bladder cancer remains controversial. Only 11.6% of the patients with stage III bladder cancer are administered perioperative (adjuvant or neoadjuvant) chemotherapy. The recommendations in various guidelines are also inconsistent. Adjuvan chemotherapy is recommended in NCCN guidelines in patients with pT3/pT4 or lymph node positive bladder cancer, but in the last version of European Association of Urology guideline, adjuvant chemotherapy is only recommended within a clinical trial. Many experts believe that adjuvant chemotherapy probably improves overall survival in high risk patients (those with extravesical disease (T3-T4) or lymph node metastases). Prospective studies had shown that adjuvant chemotherapy is effective particularly in patients with lymph node metastases. To establish this, more patients should be treated in adjuvant chemotherapy trials. Additional risk factors should be searched to identify candidates for adjuvant chemotherapy. Finally MVAC regimen (metotrexate, vinblastine, doxorubicin, cisplatin) which is currently the standard adjuvant therapy, is highly toxic and not easily tolerated by the patients postoperatively. Therefore, less toxic regimens such as gemcitabinecisplatin or non-platinum regimens should be investigated in further studies in the adjuvant setting.