The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 62-year-old man with a 45 pack per year tobacco-smoking history presented with painless gross hematuria in the fall of 2015 and was ultimately diagnosed with muscle-invasive urothelial bladder cancer. He received four cycles of cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy with pelvic lymph node dissection, which disclosed residual high-grade muscle-invasive urothelial cancer extending to the perivesical fat and involving two of 20 pelvic lymph nodes (pT3N2). Six months later, surveillance imaging identified new retroperitoneal lymphadenopathy and a large right pelvic mass with possible rectal wall invasion consistent with locally recurrent and metastatic urothelial cancer. Although feeling generally well, he reported having had progressive constipation, pelvic pressure, and narrow-caliber stools for 2 months. He was seen in consultation for management of recurrent bladder cancer.