Current treatment for rectal cancer including TME surgery and pre-operative (chemo)radiotherapy is associated with functional problems. Permanent stomas, faecal incontinence and sexual dysfunction have a great impact on quality of life. Therefore, organ-preserving treatment of rectal cancer has been introduced. Transanal excision without further treatment is only indicated in pT1 tumours with good prognostic characteristics. In more advanced tumours, pre-operative chemoradiotherapy can be used for down-staging. In patients with almost complete clinical response, transanal excision of the remaining lesion or a 'wait-and-see' policy with intensive follow-up can be implemented. Although initial cohort studies are promising, well designed prospective studies still have to prove the safety of this organ-preserving approach.