Purpose <p>The improved prognosis of rectal cancer through modern therapeutic approaches raises questions regarding quality of life (QoL) and functional outcomes. In this study, we compared post-transanal total mesorectal excision (taTME) short- and long-term QoL and functional outcomes with those after abdominal TME (abTME).</p> Methods <p>Prospective data from patients who underwent elective taTME or abTME for stage I-III rectal cancer followed by anastomosis were retrospectively propensity score-adjusted. The primary endpoint, QoL, was assessed with the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30). Functional outcomes were the secondary endpoints.</p> Results <p>Among 494 patients during 2013–2022, 187 patients who underwent taTME and 62 patients who underwent abTME were included. QoL was worse after taTME at isolated time points: overall QoL (after 3 years: 72 vs. 82 points, <i>p</i> = 0.017) and QLQ-total (after 3 years: 81 vs. 87 points, <i>p</i> = 0.028; after 4 years: 82 vs. 89 points, <i>p</i> = 0.012). After propensity score matching, the between-group differences were still significant but smaller: overall QoL − 6 points, <i>p</i> = 0.021; QLQ-total − 5 points, <i>p</i> = 0.026.</p> Conclusion <p>The differences reported at isolated time points have questionable clinical relevance. Therefore, taTME and traditional abTME seem to have comparable long-term QoL and functional outcomes.</p> Clinical trial registration <p>ClinicalTrials.gov, NCT06505863, <a href="https://clinicaltrials.gov/search?id=NCT06505863">https://clinicaltrials.gov/search?id=NCT06505863</a>.</p>