Facilitated by an enhanced appreciation for pelvic anatomy and physiology along with a better understanding of patterns of rectal cancer spread, great advances have been made in our ability to perform restorative resections for an ever-increasing proportion of mid and distal rectal cancers. Whereas oncologic results following a low anterior resection were the principal concern 20 years ago, recent efforts have focused on improving functional results as well. Aspirations for improved function need to be tempered by the realization that improved sphincter-saving rates must follow improved oncologic results rather than jeopardize them. Some crucial questions are addressed in this paper: What are the variables involved in optimizing the oncologic and functional results of a low anterior resection and a coloanal reconstruction? What are the issues involved in selecting a particular coloanal reconstruction (straight versus pouch, stapled versus handsewn, with or without fecal diversion) for a particular patient? Who is not a good candidate for a coloanal reconstruction?