OBJECTIVES: Evidence demonstrating clinical benefits of adjuvant chemotherapy following radical surgery for muscle-invasive urothelial carcinoma (MIUC) is limited. This study describes real-world treatment patterns and quantifies the economic burden of patients with MIUC undergoing radical surgery in the United States. METHODS: Adults with MIUC undergoing radical surgery (index date) between July 1, 2011, and June 30, 2019, were selected from the IBM MarketScan Commercial and Medicare Supplemental Plan databases using administrative and surgical procedure claims. Eligible patients had ≥6 months of continuous enrollment before and after index, no diagnoses of metastases before index, and no other primary cancers. Results were analyzed descriptively, and costs were adjusted to 2019 USD per patient per month. RESULTS: Among 855 patients included, mean age was 65.1 years, most were male (n=580, 67.8%), and had disease originating in bladder (n=825, 96.5%). Median follow-up from index was 16.5 months. Platinum-based multidrug chemotherapy use was limited—193 (22.6%) patients received neoadjuvant, and 26 (3.0%) received adjuvant; the most common regimen was gemcitabine plus cisplatin. Almost all patients (n=813, 95.1%) experienced ≥1 hospitalization during follow-up, with length of stay averaging 8 days. Mean medical and drug costs after surgery were $15,637, with costs slightly higher among patients without reported neoadjuvant or adjuvant chemotherapy ($16,009). Among 155 (18.1%) patients who developed metastatic disease, the mean time from index to metastatic systemic therapy was 5.4 months. These patients incurred an average of $50,161 in medical and drug costs and an increase of $331 out-of-pocket costs per month versus all patients. CONCLUSIONS: Real-world use of neoadjuvant and adjuvant chemotherapy was limited among patients with MIUC undergoing radical surgery. Metastatic disease was associated with increased resource burden. Our results signify a need for more efficacious adjuvant therapies to reduce disease recurrence and progression, and minimize healthcare resource utilization in these patients.