Background <p>Total mesorectal excision (TME) is the standard treatment for middle to lower rectal cancer. However, it is associated with significant postoperative complications and functional impairments. Local excision (LE) combined with neoadjuvant radiotherapy (RT) has emerged as a less invasive alternative and has shown potential for organ preservation. This study aimed to compare the short-term and long-term outcomes of LE + RT versus TME in selected patients with rectal cancer.</p> Materials and methods <p>This systematic review and meta-analysis were conducted following a comprehensive literature search of human studies published in English, completed by April 2025. Inclusion criteria consisted of rectal cancer up to cT3 disease and/or showed a favorable response to neoadjuvant therapy. Postoperative outcomes assessed included operative time, blood loss, morbidity, length of hospital stay, and permanent stoma rate. Oncological and survival outcomes were also evaluated.</p> Results <p>A total of six studies were included. They consisted of five randomized controlled trials and one prospective clinical trial, with a total of 679 patients. Of these, 366 were treated with LE + RT and 313 with TME. Pooled analysis showed that the LE + RT group was associated with a significantly shorter operative time, a lower overall morbidity, and a shorter postoperative hospital stay. No significant differences were observed between the groups in oncological or survival outcomes.</p> Conclusions <p>This study suggests that, in selected rectal cancer patients, LE + RT may represent a less invasive alternative with comparable oncological outcomes to TME. LE + RT may subsequently be a viable treatment option, especially in patients seeking organ preservation or in patients unfit for TME.</p>