Rectal resection is the most common treatment of rectal cancer and inflammatory bowel disease. The surgical techniques for removing and reconstructing the rectum have evolved significantly over the past 50 years. Technological advances including retractors, stapling devices, energy delivery systems, and minimally invasive approaches, as well as the nerve-sparing total mesorectal excision, have revolutionized the surgical treatment. Surgical exposure and precise technique affect the ability to preserve the pelvic autonomic nerves, directly influencing postoperative urinary and sexual function. The complex interplay between all these factors demands attention because of the associated short-term and long-term impact on patient quality of life.