In locally advanced rectal cancer, neoadjuvant chemoradiotherapy provides a significant benefit to local cancer control in addition to total mesorectal excision. However, in 10–40% of all patients, a complete clinical remission can be detected after completion of chemoradiotherapy. Recent studies have shown that those patients omitting radical surgery after successful neoadjuvant pretreatment can be safely managed within a close follow-up network without compromising short-term overall and disease-free survival. However, available data suggest that 20–30% of all patients assigned to a watch and wait regimen will eventually have to be transferred to surgical management due to local recurrence. Careful patient selection is key for a successful watch and wait approach and the choice of non-operative management should not be made after completion of staging but rather after neoadjuvant chemoradiotherapy. Selected patients need to be thoroughly informed that there is still no standardized follow-up protocol and no predefined follow-up period.