PURPOSE: Differences exist between Japan and The Netherlands in the treatment of low rectal cancer. The purpose of this study is to analyze these, with focus on the patterns of local recurrence. METHODS: In The Netherlands, 755 patients were operated by total mesorectal excision (TME) for low rectal cancer, 379 received preoperative radiotherapy (RT+TME). Applying the same selection criteria resulted in 324 patients in the Japanese (NCCH) group, who received extended surgery consisting of lateral lymph node dissection and a wider abdominoperineal excision. The majority received no (neo) adjuvant therapy. Local recurrence images were examined by a radiologist and a surgeon. RESULTS: Five-year local recurrence rates were 6.9% for the Japanese NCCH group, 5.8% in the Dutch RT+TME group, and 12.1% in the Dutch TME group. Recurrence rate in the lateral pelvis is 2.2%, 0.8%, and 2.7% in the Japanese, RT+TME group, and TME group, respectively. The incidence of presacral recurrences was low in the NCCH group (0.6%), compared with 3.7% and 3.2% in the RT+TME and TME groups, respectively. CONCLUSIONS: Both extended surgery and RT+TME result in good local control, as compared with TME alone. Preoperative radiotherapy can sterilize lateral extramesorectal tumor particles. A wider abdominoperineal resection probably results in less presacral local recurrence. Comparison of the results is difficult because of differences in patient groups.