Background <p>Abdominoperineal resection (APR) for very low rectal cancer often causes long-term QoL issues due to a permanent colostomy and pelvic morbidity. Dual-stoma techniques, like appendicostomy-enabled irrigation, might enhance bowel control and psychosocial recovery, but these methods need more study in large prospective cohorts.</p> Objective <p>Appendicostomy with abdominal colostomy during APR improves long-term QoL without increasing complications.</p> Methods <p>A ten-year prospective cohort study across three Iranian colorectal centers involved 130 participants undergoing standardized APR with dual-stoma formation, including a permanent colostomy and appendicostomy. QoL was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and the colorectal cancer-specific module (QLQ-CR29) at 12, 18, and 24 months. Missing responses were addressed through multiple imputation. Nonparametric methods like Mann–Whitney, Kruskal–Wallis, and Spearman’s correlation evaluated trends and disparities across domains and sociodemographic variables.</p> Results <p>The mean QoL score was 81.5 ± 11.3. Functional domains, including cognitive (94.6 ± 12.5), role (89.5 ± 13.5), and physical (85.0 ± 12.1), remained consistently high. CR29 scores indicated strong body image (75.9 ± 16.0), minimal stoma-related embarrassment (29.5 ± 21.0), and maintained sexual function (74.9 ± 24.6 among active respondents). Issues concerning appendicostomy management were minimal, with 91.5% of participants reporting ease of use; no severe complications were observed. Persistent concerns included financial burden (35.6 ± 23.2) and mild peri-stomal symptoms.</p> Conclusion <p>Dual-stoma APR with appendicostomy is a safe, feasible, and associated with favorable physical, psychosocial, and functional QoL outcomes.</p>