<p>Extralevator abdominoperineal excision (ELAPE) improves surgical margins in distal rectal cancer compared to conventional amputation; however, it is associated with higher rates of perineal morbidity. This study aimed to evaluate the incidence of perineal infections and identify associated risk factors in patients with rectal adenocarcinoma undergoing ELAPE with perineal reconstruction using an absorbable synthetic prosthesis. This prospective observational study including consecutive patients treated between 2009 and 2024. All patients underwent standardized perineal reconstruction with an absorbable synthetic prosthesis. Clinical, tumor, surgical, and postoperative complication variables were recorded. Univariate and multivariate analyses were performed to identify factors associated with perineal infection. A total of 61 patients were analyzed. Perineal infection occurred in 23%, with most infections developing within the first 30 postoperative days. Multivariate analysis identified obesity (Odds Ratio [OR] 74.3), active smoking (OR 33.7), and circumferential margin involvement observed on basal magnetic resonance imaging (OR 28) as independent risk factors. Patients with perineal infection had longer hospital stays, more readmissions, more postoperative visits, and higher complications severity. Infection was not associated with an increased rate of perineal hernia, which was low in our cohort (3%). In conclusion,&#xa0;perineal reconstruction with an absorbable synthetic prosthesis following ELAPE is safe and effective. Identification of patients at high risk for perineal infection enables targeted preventive strategies and informs future comparative studies of perineal reconstruction techniques.</p> Graphical abstract <p></p>