Functional outcomes following local excision for rectal neoplasms are important measure­ments for assessing risk of the procedure and for obtaining appropriate informed consent. While safety, feasibility, and oncologic soundness of transanal surgical approaches have largely been the focus of early studies involving TEM and TAMIS, a shift toward investigating the effects of newer technology on anorectal function and quality of life has occurred. The insertion and utilization of either an anoscope or a minimally invasive platform can affect the sphincter com­plex and potentially cause postoperative dys­function. Careful consideration to preoperative functional status is warranted to avoid exacerba­tion of existing continence issues and for setting appropriate expectations for potential distur­bances in continence and quality of life in the postoperative setting. Size of tumor, location within the rectum, extent of resection, duration of surgery, age, and female gender have been postulated to affect functional outcomes; how­ever, no robust data exist to uniformly vilify any preoperative or intraoperative factor. There is a singular exception: Patients who have received chemoradiation therapy prior to transanal exci­sion have been shown to have an elevated risk for postoperative anorectal dysfunction [23, 31, 32]. While injury to the sphincter complex and rectal wall is possible during transanal excisional sur­gery, the majority of continence and quality of life data demonstrate acceptable results and sup­port the use of transanal surgical approaches over traditional proctectomy when oncologically appropriate.