Purpose: Neoadjuvant chemotherapy (NAC) before radical cystectomy is the standard of care for muscle-invasive bladder cancer (MIBC) due its survival benefits. Historically, uptake is suboptimal particularly in areas with limited healthcare access. This study aims to re-evaluate in a contemporary cohort the NAC and adjuvant chemotherapy (AC) uptake among rural and metropolitan patients at a tertiary institution. Methodology: We retrospectively analysed patients undergoing radical cystectomy for ≥ pT2 urothelial carcinoma from 2011 to 2021. Patients were categorized into metropolitan or rural cohorts using the Modified Monash Model. Results: Among 69 patients, 46 (66.7%) were from metropolitan areas, and 23 (33.3%) from rural areas. NAC uptake was low overall, with a higher proportion of rural patients receiving NAC (26.6% vs. 10%, p = 0.21) compared to metropolitan patients. Among patients eligible for AC, a higher proportion of metropolitan patients were offered treatment compared to rural patients (91.67% vs. 61.54%, p = 0.072). However, the proportion of patients who ultimately received AC was similar between the two groups (68.18% for metropolitan vs. 50.0% for rural; p = 0.17). The primary reasons for non-receipt in the rural cohort was planning to receive therapy elsewhere (25%) whereas in the metropolitan cohort it was patient declination (22.7%). Conclusion: This study demonstrates that rural status does not significantly affect chemotherapy uptake or survival outcomes. However, rural patients continue to face unique barriers to accessing quality cancer care. Ongoing efforts are essential to further ensure equitable access to guideline-based treatment for MIBC for all patients.