Surgeons face critical choices between low anterior resection (LAR) and abdominoperineal resection (APR) for low rectal cancer, as outcomes vary and affect patient quality of life.

• No significant long-term difference in overall quality of life: LAR (68.3) vs. APR (71.2).
• Major low anterior resection syndrome impacted 44.9% of LAR patients; 31.3% of APR patients reported poor stoma-related quality of life.

Individual patient priorities must shape surgical decisions to optimize outcomes.

• Factors like neoadjuvant chemoradiotherapy and tumor distance ≤3 cm are linked to major low anterior resection syndrome.