BACKGROUND: The management of rectal cancer has been transformed by advances in neoadjuvant treatments, leading to complete response in approximately 30% of cases and making a watch-and-wait (W&W) strategy feasible; however, this approach is associated with a local regrowth (LR) rate of up to 30%, and the management of LR remains non-standardized. OBJECTIVE: We aimed to compare the oncological and quality-of-life outcomes of salvage total mesorectal excision (TME) versus local excision (LE) for LR following W&W in an expert colorectal surgery center. METHODS: This retrospective analysis included prospectively registered patients with mid and low rectal cancer who achieved complete response after neoadjuvant treatment and were subsequently managed with a W&W strategy at Bordeaux University Hospital between 2015 and 2022. The choice of treatment for LR was based on patient preferences, comorbidities, and multidisciplinary team recommendations. PATIENTS: A total of 103 patients were included in the W&W cohort. Among these patients, 33 (32%) developed LR, of whom 17 underwent TME, 13 underwent LE, and 3 presented with distant metastases and were not eligible for surgery. MAIN OUTCOMES: The new LR rate was significantly higher in the LE group compared with the TME group (4 vs. 0 patients; p = 0.02). Additionally, 54% of patients in the LE group ultimately required salvage TME (n = 7/13). The LE group reported poorer quality of life in terms of mobility (p = 0.019) and anxiety/depression (p = 0.001). CONCLUSION: A second attempt at organ preservation using LE after W&W failure may expose patients to increased oncological risk and inferior functional outcomes compared with those undergoing salvage TME. These findings highlight the need for cautious patient selection and standardized protocols when considering LE for LR following W&W.