The majority of rectal cancer recurrences develop within the pelvis but outside the bowel. In clinical practice these tumours have been palpable in the pelvis for some time before a positive mucosal biopsy is obtained at the time when the cancer penetrates the mucosa of the neorectum or vagina. We present our experience with transrectal digitally guided fine needle aspiration cytology (FNAC) taken through intact mucosa or from intraluminal tumours. The sensitivity of the cytology was 0.88 versus 0.68 of the fine needle core biopsy (FNCB) specimens (p < 0.005); no false positive cancer diagnoses were reported. The simple and cost-effective digitally guided transrectal biopsy procedure may be adequate for an early morphological diagnosis, avoiding the more expensive CT or ultrasonically guided biopsies. It is safe and easy to take the biopsies and the complication rate is low. Surgical treatment for locally recurrent rectal cancer is justified. In combination with radiation therapy, it offers pain relief and improved quality of life. Survival is prolonged and cure can be achieved in up to one third of patients.