Purpose <p>Transanal approaches have been developed to improve the quality of surgery for lower rectal cancer; however, international concerns have been raised about higher local recurrence rates. We investigated the short- and long-term outcomes of the transanal approach.</p> Methods <p>A total of 291 patients who underwent laparoscopic or robotic surgery for rectal cancer were enrolled in this retrospective study. Clinical, pathological, surgical, and follow-up data were reviewed and patients were divided into a transanal approach group (<i>n</i> = 139) and a conventional total mesorectal excision group (<i>n</i> = 152). A propensity score-matched analysis was performed to compare surgical outcomes.</p> Results <p>After matching, 65 patients were included in each group. In the transanal group, intersphincteric resection was performed more frequently and abdominoperineal resection was less, resulting in a higher rate of anus preservation (72.3% vs. 53.8%). The operative time was shorter, blood loss was lower and major complications were less frequent in the transanal group. Overall survival was better in the transanal group. No significant difference was observed in the total recurrence rate, including the local recurrence rate.</p> Conclusions <p>The transanal approach for lower RC can be performed safely without compromising short- and long-term outcomes, offering a higher rate of anus preservation.</p>