Organ preservation with maintenance of function in the treatment of rectal cancer is highly valued by patients. Although most patients with resectable rectal cancer can undergo a sphincter-sparing radical procedure, there are patient, tumor, surgeon, and treatment factors that influence the ability to restore intestinal continuity after radical resection. Although population-based data suggest that the rate of sphincter preservation is lower than could be obtained at expert centers, there are patients in whom low anterior resection with colo-anal anastomosis is not technically feasible and/or oncologically sound. Additionally, resection with ultralow anastomosis results in functional compromise in many patients. Local treatment of rectal cancer aims to decrease the morbidity and the functional sequelae associated with radical resection; however, local excision is associated with a higher rate of local recurrence than is radical resection. Strict selection criteria are essential when considering local excision, and patients should be informed of the risk of local recurrence. The use of adjuvant therapy with local excision, particularly in patients with T2 lesions, has promise but should be considered only as part of a clinical trial.