Laparoscopy, robotic-assisted, and transanal techniques showed mixed success in high-risk rectal cancer patients, all falling short of expected outcomes.

• Primary outcome rates: 82.4% (laparoscopy), 64.3% (laparotomy), 74.7% (robotic), and 80.3% (transanal).
• 96% R0 resection rate across all techniques; no significant difference found.
• Conversion rates for minimally invasive methods remained consistent at 4.5%.

Surgeons should consider that while minimally invasive options are viable, none consistently met benchmarks for success, emphasizing the need for careful patient selection.