Transanal endoscopic microsurgery (TEM) is a minimally invasive surgical techniquethat was developed more than two decades ago to manage distal colorectal neoplasias.The aimof the current study was to present a prospective review of 7 years of experiencein using this equipment. All patients undergoing TEM between 1999 and 2007 wereprospectively evaluated. Patients underwent regular endoscopic follow up. Cumulativeincidence probability analysis was used to calculate rates of recurrence. The studyinvolved 232 patients, median age 68 years (interquartile range (IQR), 37–90). Themedian neoplasia area was 12 cm2 (IQR, 6–25 cm2) and the median height above theanal verge was 9 cm (IQR, 3–17 cm). Histology indicated 128 adenomas, 52 carcinomasin situ, and 52 adenocarcinomas. The median postoperative stay was 1 day (IQR,1–3 days). There was one (0.5%) unplanned return to theatre and no postoperativedeaths. Sixteen patients (6.9%) underwent more radical surgical procedures followingthe identification of carcinoma in the resected specimen. During a median follow up of4.2 years (IQR, 2.6–6.2 years), the 5-year cumulative incidence for local recurrence forbenign pathology was 3.1% (95% confidence interval (CI): 1.2–6.7%, n = 180) and forcancers managed primarily by TEM excision it was 8.5% (95%CI: 1.4–23.9%, n = 36).TEM is an excellent treatment modality for benign rectal neoplasias of any size, and inany location. TEM is an oncologically inferior treatment for rectal cancer, however,when compared to more radical treatments. Its principal advantage in this setting is thatit is associated with relatively minimal morbidity and mortality.