Data from cancer registries show that incidence of rectal cancer is still high in Italy, while mortality rates are slightly decreasing in most recent years. Surgery is the treatment of choice and in most cases with curative intent. The rectum may be defined as the tract of the large bowel distal to 12 cm from the anal verge. Tumors located in that segment show local recurrence rates higher than those for tumors located proximally. Pelvic recurrence is evident as a regrowth of cancer in and around the tumor bed. Powerful imaging techniques have been developed for the early and appropriate evaluation of pelvic recurrences. A wide range of recurrence rates after operation for rectal cancer are reported, spanning from 3% to over 30%. The main determinants of local recurrence are related to the tumor and to the treatment. Among the former, stage at diagnosis and number of lymph nodes involved are the most important, along with inadvertent perforation of the intestine and location of tumor in the rectum. Among treatment factors, type of operation and experience of the operator should be mentioned. A major advancement in rectal surgery has been the implementation of total excision of the mesorectum. This technique has decreased dramatically recurrence rates of rectal cancer, though increasing the risk of local complications. Preoperative radiotherapy seems to confer a slight further advantage in selected cases. Management of locally recurrent tumors is still unsatisfactory and surgery is feasible only in less than 10% of cases.