Locally advanced rectal cancer dictates a major surgical undertaking, which includes en bloc resection of the rectum and all involved organs. The aim of this study was to evaluate patient outcome and compare multimodality treatment options after various surgical approaches from one institution for T4 rectal cancer. A retrospective chart review identified 24 patients who were operated on for advanced primary rectal cancer invading adjacent structures (T4) over a 5(1/2)-year period. The types of treatment and outcome were analyzed. From these 24 patients, the most frequently involved organ was the bladder (33%). A total of 16 patients underwent chemoradiotherapy. There were 12 complications (50%), the most common being wound infection (33% of complications, 17% overall). Nine patients had nodal disease. Disease-free survival was 54 per cent, and overall survival was 75 per cent. However, disease-free survival in node-negative patients was 67 per cent versus 33 per cent in node-positive individuals. Out of the six patients who died in this review, five (83%) received chemoradiotherapy. Operations for advanced primary rectal cancer with involvement of adjacent organs are major procedures associated with high morbidity. Patients without nodal disease may have long-term survival despite the locally advanced tumor. Interestingly, neoadjuvant therapy, adjuvant, or both, did not increase survival.