Transanal total mesorectal excision (TATME) offers promising long-term oncologic outcomes for rectal cancer patients, with a low local recurrence rate of 4.55% at five years.

• In a cohort of 220 patients, overall survival was 60.91% and disease-free survival was 58.6% at five years.
• Anastomotic leakage was identified as the strongest predictor of both local (HR: 4.01) and distant recurrences (HR: 3.58 for positive nodal status, HR: 3.91 for anastomotic leakage).

These findings emphasize the need for meticulous surgical technique to enhance long-term outcomes in rectal cancer surgery.