Current treatment of mid and lower rectal cancer includes neoadjuvant therapy, such as radiotherapy or radiochemotherapy. Randomized trials have demonstrated that neoadjuvant therapy improves local control. However, with the exception of one study, it does not improve overall and cancer-specific survival. In addition, the role of neoadjuvant therapy in enhancing the surgeon's ability to perform sphincter-saving surgery is still controversial. We provide an overview of reported randomized trials using neoadjuvant therapy in patients with rectal cancer. We have examined the most significant factors influencing sphincter preservation and the manner in which these factors are affected by neoadjuvant treatment.