The possibility of a permanent stoma has always been one of the main concerns of patients diagnosed with rectal cancer. Even though patients’ perspectives may vary across different geographical areas and cultures, a permanent end-colostomy impacts body image and impairs quality of life [23]. The concept of avoiding surgery in rectal cancer patients treated with neoadjuvant chemoradiation was driven by the observa­tion of pCR in patients treated with abdominal-perineal resection (APR) with permanent colostomy [4]. Following similar observations from anal cancer treatment, where patients with complete tumor regression after neoadjuvant chemoradiation (nCRT) avoided radical surgery with sur­prisingly favorable oncological outcomes, initial attempts were made to identify rectal cancer patients who had achieved a pCR, by means of clinical, endoscopic, and radio­logical examination [24]. However, most rectal cancer patients have more surgical options than anal cancer patients, for whom APR is the main radical surgical alternative. Depending on tumor stage, anatomy, and relation to the anal sphincter complex, many rectal cancer patients are candi­dates for sphincter preserving procedures. Although avoid­ing a permanent stoma, restorative proctectomy is often associated with signicant bowel dysfunction, particularly worsened by previous exposure to ionizing radiation to the pelvis. A sizeable fraction of patients who undergo a restor­ative procedure with their temporary diverting stoma reversed are left with variable degrees of fecal incontinence and a constellation of symptoms known as “low anterior resection syndrome,” some requiring conversion to a permanent stoma or creation of cecostomy/appendicostomy for anterograde colon lavage [25–27]. In addition, proctectomy, with or with­out sphincter preservation, has signicant consequences in terms of sexual and urinary function [28, 29].