Radical cystectomy is one of the most drastic procedures that urological patients have to undergo with a five-year mortality of around 50% in those with organ-confined disease at presentation. Traditional imaging is with contrast-enhanced computed tomography (CT) but lymphadenectomy often unearths occult disease and infers a worse prognosis. This study was a retrospective analysis of the benefits of using positron emission tomography (PET) / CT to enhance staging and establish how further management was affected. Over a 32-month period, all patients with muscle invasive bladder cancer, or high-grade superficial disease, were staged with standard CT imaging and then subsequent PET/CT within 30 days, with analysis of the treatment decisions based on each modality. Nodes of over 10mm were deemed positive on CT and the gender ratio was 3:1 (male to female) in keeping with other studies. All suspicious lesions were confirmed with biopsy. Of 166 possible patients, 96 met the inclusion criteria. CT and PET/CT agreed in 78.1% of cases, with 19.8% being upstaged and 2.1% down-staged (i.e. a total of 21.9% variation in staging). The treatment recommendation of 13 patients changed to a higher category after PET/CT review, with 12.7% of the possible cystectomy cohort requiring neoadjuvant therapy and in 8.5%, curative intent changed to palliation. Ten unrelated lesions were found in eight patients, eight in the bowel and two lung lesions, resulting in the management of four patients becoming palliative and two required extra surgery. Other less robust studies have shown similar benefits of PET/CT staging, but ideally correlation between imaging and pathological specimens and ultimately disease-specific survival will determine its true use. There are cost implications and technological advances to consider but any means of improving patient stratification to the appropriate treatment must be welcomed, to avoid futile procedures and to improve outcomes.