Bladder cancer patients with a positive surgical margin after radical cystectomy have a median recurrence free survival of less than one year. A recent survey of practicing radiation oncologists in the United States reports that almost half recommend adjuvant radiation therapy (RT) for locally advanced bladder cancer with over 90% of this group supporting the use of adjuvant RT for positive surgical margins. We sought to determine whether these physician treatment recommendations are reflected in national practice patterns. Using the National Cancer Database (NCDB), we identified patients diagnosed with non-metastatic urothelial cell or squamous cell bladder cancer from 2004 to 2014 who were treated with radical cystectomy. We studied patterns of care with regards to receipt of adjuvant RT in the overall cohort and in the positive surgical margin subgroup. Multivariable logistic regression was used to identify factors associated with receipt of adjuvant RT. 46,380 patients met inclusion criteria for the overall cohort of which only 488 (1.1%) received adjuvant RT. In the overall cohort, receipt of adjuvant RT was significantly associated with squamous cell carcinoma histology (OR=4.10, 95%CI 3.16-5.32; p<0.001), higher pathologic T stage (OR=13.6, 95%CI 1.89-97.76; p=0.01), and positive surgical margins (OR=3.76, 95%CI 2.95-4.81; p<0.001). Other variables significantly associated with receipt of adjuvant RT included treatment at non-academic facilities, receipt of chemotherapy, and earlier year of diagnosis. Notably, age, race, comorbidity, and pathologic N stage did not impact receipt of adjuvant RT. There were 2,766 patients in the positive surgical margin subgroup of which only 120 (4.3%) patients received adjuvant RT. The utilization of adjuvant radiation in positive margin patients did not vary substantially over the study period. In 2004, 14/160 (8.8%) patients received adjuvant RT while 14/289 (4.8%) patients received adjuvant RT in 2014. On multivariable analysis, receipt of adjuvant RT was significantly associated with treatment at non-academic facilities, squamous cell carcinoma histology, receipt of chemotherapy, and an earlier year of diagnosis. In this patterns of care study, less than 5% of patients with positive surgical margins following radical cystectomy received adjuvant radiation therapy from 2004 to 2014. There appears to be a large discrepancy between the inclinations of practicing radiation oncologists and the actual practice patterns for this patient subgroup despite poor overall outcomes. These findings suggest that further work is needed to understand the risks and benefits of adjuvant RT, and may reflect a lack of multi-disciplinary care in the management of locally advanced bladder cancer.