In patients with cancers of the lower rectum, advanced surgical techniques have been developed which allow for avoidance of a permanent stoma. These techniques include trans-anal local excision, a coloanal J pouch anastomosis and the use of neoadjuvant therapy prior to surgery. Local excision is removal of the rectal tumor through the anus. It allows removal of the tumor with no incisions on the abdomen and usually a 1 night hospital stay with a quick recovery. Coloanal J pouch is an operation that removes advanced rectal cancers located close to the anal sphincter muscles. The procedure consists of removing the entire rectum but preserving the anal canal and sphincter muscles. A pouch is then formed from the colon and this pouch which increases the storage capacity is then sewn inside the anal canal thus preserving continence. For very large or advanced tumors which can not be removed initially without a colostomy, we use neoadjuvant therapy to first shrink the tumor. Neoadjuvant therapy consists of radiation and a mild chemotherapy that is given on an outpatient basis for approximatley 3 months before surgery. We wait an additional 6 weeks after the neoadjuvant therapy has completed to allow for maximal shrinkage of the cancer. By using neoadjuvant therapy first, removal of the cancer is possible with sphincter sparing surgery and avoidance of a permanent colostomy.