Radical treatment of rectal cancer has evolved quite significantly over the last few decades with the development of optimal local disease staging with magnetic resonance (MR), refined surgical techniques including total mesorectal excision (TME) with or without sphincter-preservation, and multimodality treatment with the use of chemotherapy and radiation. While oncological outcomes have shown some significant improvements in terms of local disease control and distant metastases rates, complication rates and functional sequelae remain quite significant for patients undergoing TME surgery. In this setting, organ-preserving alternatives, including transanal local excision (TAE) and Watch and Wait (WW), have become increasingly attractive to patients in an attempt to avoid major surgery (TME) as an alternative treatment strategy with no oncological compromise. In the present narrative review, the fundamentals of selection and outcomes of patients undergoing WW will be covered to provide updated information for colorectal surgeons and surgical oncologists interested in this treatment alternative in clinical practice.