Abstract: Neoadjuvant chemoradiotherapy (nCRT) and subsequent radical resection have become the standard care of locally advanced rectal cancer (LARC). However, conventional radical surgery is associated with high intra-and post-operative morbidities, and a temporary or permanent stoma in some cases, impaired sexual and urinary function, and it eventually impair the quality of life. “Rectum-preserving surgery” is a novel concept in the era of nCRT, which will maximally benefit patients through the minimized injuries. This strategy has been increasingly utilized in LARC following nCRT. Nevertheless, it lacks high-level evidence of evidence based medicine, and the long term oncological safety remains to be determined by larger, multicenter, randomized clinical trials. The crucial aspect of “rectum-preserving surgery” is to accurately evaluate the status of primary tumor and metastatic lymph nodes, and thus to selective patients who could benefit from this strategy most.