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Introduction: The number of elderly patients with bladder cancer is expected to triple in the coming years in proportion to the increasing elderly population in the world. The aim of this study was to identify the prognostic factors affecting survival among elderly patients undergoing chemoradiotherapy for muscle-invasive bladder cancer. Materials and Method: We retrospectively reviewed medical records from 93 biopsy-proven nonmetastatic elderly patients with bladder cancer = 65 years who were treated with helical tomotherapy. The patients received 64.8 Gy to the bladder with concurrent intravenous cisplatin (40 mg/m2) chemotherapy weekly as a radiosensitizer. Results: The mean follow-up time was 34.1 months (range, 4.0-99.1 months). The two- and five-year overall survival, disease-free survival, and cancer-specific survival rates were 70.6%, and 36.9%, 50.6% and 28.5%, 89.1%, and 58.5%, respectively. Multivariate analysis indicated that urothelial obstruction was an independent prognostic factor affecting survival rates. No grade 4 adverse events and deaths attributable to treatment occurred during chemoradiotherapy Conclusion: Image guided radiotherapy with chemotherapy as a bladdersparing approach is a tolerable alternative therapeutic option without severe acute and late toxicities in elderly patients who are unfit for radical cystectomy or refuse surgery. [ABSTRACT FROM AUTHOR]