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Local recurrence (LR) after surgical resection for adenocarcinoma of the rectum still remains an unsolved problem. Local relapse often occurs when tumor spreads in perirectal fat (mesorectum) or along the lateral iliac lymph nodes also when surgery is considered radically. There is a close relationship between local recurrence rate and lymphatic involvement, local tumor extension and tumour grading. Total mesorectal excision (TME) appears to be associated with a reduced LR rate when resection of perirectal fat is done “en-bloc” and when a negative radial margins is obtained. TME allows autonomic nerve sparing and sphincter preservation too, but lateral nodes are not treated by TME. Extended lymphadenectomy with lateral dissection for advanced rectal cancer has been often associated with an increase rate of long term morbidity, particularly regarding urinary and sexual function. Concomitant preoperative chemo-radiation for advanced rectal cancer is a relatively safe procedure with an acceptable morbidity and mortality. This approach is associated with a considerable clinical and pathologic tumor downstaging. Tumor resectability is improved and lateral spreading is also better controlled. An improving in survival and a longer disease free period has been reported. More radical sphinc – ter saving operations are also allowed.