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This review explored recent advancements in organ preservation strategies for early rectal cancer. Although total mesorectal excision (TME) remains the standard treatment, there is a growing interest in organ preservation approaches due to the potential decline in quality of life associated with TME. We discussed precise staging methods for early rectal cancer and proposed specific organ preservation protocols for cT1N0M0 and cT2N0M0 patients. Additionally, immunotherapy has shown significant potential for patients with deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) status. This review summarized current research findings and provided guidance for clinicians on organ preservation options when treating early rectal cancer.