Abstract: Muscle-invasive bladder cancer (MIBC) is a rare but highly fatal malignancy characterized by its invasiveness. It spreads rapidly to surrounding tissues and has a high risk of recurrence, imposing substantial physical, psychological, and economic burdens on patients during treatment. Traditional treatment methods, such as radical cystectomy, can effectively remove tumors and prevent further spread; however, they also impose significant psychological stress and markedly reduce patients’ quality of life. Therefore, the medical community has begun to seek more humanized and individualized treatment strategies to alleviate patient suffering. With the continuous advancement in medical research, antibody-drug conjugates (ADCs) have emerged as a novel targeted therapeutic approach for treating various cancers. Particularly in bladder-preserving treatment of MIBC, ADCs have attracted considerable attention owing to their unique mechanisms of action and potential therapeutic effects. This article aimed to review recent research on ADC in bladder-preserving treatment for MIBC; explore the application models, mechanisms of action, and effectiveness of clinical trials of such drugs in neoadjuvant therapy, adjuvant therapy, and combination therapy; analyze the potential of ADC in neoadjuvant therapy; and discuss the effect of ADC as an adjuvant treatment method, which can be combined with other therapies such as radiotherapy or chemotherapy, to enhance the overall therapeutic effect.