Introduction <p>Rectal-sparing strategies for locally advanced rectal cancer are gaining interest owing to favorable oncological results and reduced impact on functional outcomes. In patients managed with watch-and-wait or local excision after neoadjuvant chemoradiotherapy (nCRT), local regrowth occurs in approximately 15–30% of cases. Total mesorectal excision (TME) is the standard treatment for regrowth; however, local excision (LE) may be considered in selected cases to preserve rectal function. This narrative review evaluates clinical and oncological outcomes of patients undergoing LE for suspected regrowth.</p> Methods <p>A narrative review of the literature was conducted using databases and search terms including “rectal cancer,” “rectal sparing,” and “local regrowth.”</p> Results <p>Five retrospective studies were identified, encompassing a total of 159 patients. Treatment protocols, neoadjuvant regimens, and follow-up strategies varied across the studies. Histopathological findings revealed ypT ≥ 2 in 45.3% of cases. Reported overall survival (OS) was consistently above 94.5%, while 2-year locoregional recurrence-free survival ranged from 74% to 85%. Systemic recurrence occurred in 9.1% of patients. LE was associated with shorter operative time, reduced blood loss, and lower rates of Clavien–Dindo ≥ 3 complications.</p> Conclusions <p>Local excision for regrowth may represent a feasible alternative to radical surgery in selected patients, particularly within specialized centers and under strict surveillance protocols. Further prospective studies are warranted to validate its long-term oncologic safety and functional outcomes.</p>