We present the case of a 53-year-old man with a 25-pack/year smoking history and a 6-month history of gross hematuria, who presented with a pT3a, N0, M0, muscle invasive bladder cancer (MIBC). He declined neoadjuvant chemotherapy, but received post-cystectomy adjuvant chemotherapy. Six months post-adjuvant chemotherapy, he presented with abdominal pain and a large bowel obstruction, and was found to have an isolated rectal recurrence of MIBC. This case illustrates 2 important issues: (1) patients with a smoking history and symptoms of hematuria need to be carefully evaluated to rule out urothelial cancer; and (2) in patients with muscle invasive disease, local pelvic recurrence is common and close surveillance for recurrence needs to be implemented.