OBJECTIVES: The aim of this study was to compare the perioperative and oncological results of completion total mesorectal excision (cTME) primary total mesorectal excision (pTME). BACKGROUND: Early-stage rectal cancer can be treated by local excision alone, which is associated with less surgical morbidity and improved functional outcomes compared with radical surgery. When high-risk histological features are present, cTME is indicated, with possible worse clinical and oncological outcomes compared to pTME. METHODS: This retrospective cohort study included all patients that underwent TME surgery for rectal cancer performed in 11 centers in the Netherlands between 2015 and 2017. After case-matching, we compared cTME with pTME. The primary outcome was major postoperative morbidity. Secondary outcomes included the rate of restorative procedures and 3-year oncological outcomes. RESULTS: In total 1069 patients were included, of which 35 underwent cTME. After matching (1:2 ratio), 29 cTME and 58 pTME were analyzed. No differences were found for major morbidity (27.6% 19.0%; = 0.28) and abdominoperineal excision rate (31.0% 32.8%; = 0.85) between cTME and pTME, respectively. Local recurrence (3.4% 8.6%; = 0.43), systemic recurrence (3.4% 12.1%; = 0.25), overall survival (93.1% 94.8%; = 0.71), and disease-free survival (89.7% 81.0%; = 0.43) were comparable between cTME and pTME. CONCLUSIONS: cTME is not associated with higher major morbidity, whereas the abdominoperineal excision rate and 3-year oncological outcomes are similar compared to pTME. Local excision as a diagnostic tool followed by completion surgery for early rectal cancer does not compromise outcomes and should still be considered as the treatment of early-stage rectal cancer.