Improved understanding of the biological features and advances in diagnostic and surgical procedures have been the basis for increased applications of sphincter-preserving operations in lower rectal tumors. The relevant treatment strategies along with their indications will be presented and analyzed. New operative procedures comprise transanal excision of early rectal cancer or trans-sphincteric resection or ultralow anterior resection with colon-pouch creation to improve continence. Recently, for cases in which the removal of the rectal sphincter is indispensible for oncological reasons, a continent perineal colostomy has been developed. Reconstruction of the sphincter function is achieved using a seromuscular cuff. This procedure avoids an abdominal colostomy. The neosphincter can also be formed secondarily, after a prior abdominoperineal excision with a transabdominal colostomy.