The most difficult question for many rectal cancer patients after being diagnosed is whether the anus can be preserved or not. The purpose of anal preservation is undoubtedly to improve patients’ quality of life after surgery, but will anal preservation surgery affect the local recurrence of tumor? How to balance between anal preservation and local recurrence? Of course, it is ideal to preserve anus and not to increase the rate of local recurrence, but sometimes it is difficult to have both. When the fish and the bear’s paw cannot be combined, we should think of “anus is valuable, life is more expensive! The prerequisite for anal preservation surgery is to achieve the purpose of radical cure, followed by effective preservation of the anal sphincter function. If we cannot achieve the goal of local radical resection and preserve the anus, the local tumor will recur soon and then metastasize and endanger the life, which is the price of life. Another situation is that although radical local excision is achieved, the function of anal sphincter cannot be effectively preserved, feces cannot be controlled, and disposable diapers have to be used all day long, and fecal juice stimulating perianal skin will cause perianal skin erosion and ulceration, which is very painful and its quality of life is far inferior to that of patients who have abdominal wall artificial anus. So which rectal cancer patients can have anal preservation surgery? The location of the tumor, the stage of the tumor, the differentiation of the cancer cells, the function of the anal sphincter before surgery and the experience of the surgeon should be taken into consideration, and most of the middle and high rectal cancers can be anus-preserving, while a few low rectal cancers with early stage and better differentiation of the cancer cells can be anus-preserving with appropriate surgery. For low-grade rectal cancer with advanced stage or poor preoperative anal sphincter function, combined abdominoperineal resection (Miles’ procedure) should be considered instead of anus-preserving surgery. Anal preservation surgery includes: 1) local excision of rectal cancer, 2) transabdominal rectal cancer resection followed by low or ultra-low anastomosis or Parks surgery, and 3) intersphincter resection (ISR).