Neoadjuvant chemoradiation followed by proctectomy is the recommended treatment plan for locally advanced rectal cancer in the USA. After chemoradiation, approximately 20 % of patients experience a complete pathologic response, which is associated with improved oncological outcomes. This observation prompted questions about the necessity of surgery if the tumor has completely regressed. Using clinical complete response as a surrogate for pathologic response, the watch and wait approach was introduced as an attempt at organ preservation utilizing active surveillance protocols rather than surgery. Prospective studies have highlighted the potential benefits of this approach, with successful organ preservation and comparable oncologic outcomes. Non-operative protocols are based on thorough response assessment using clinical exam, imaging, and laboratory tests with frequent repeat examinations to detect residual or recurrent disease in a timely manner. Although a subset of patients benefit from this approach, accurate identification of appropriate patients remains challenging. Debate continues regarding use of non-operative surveillance or standard proctectomy in patients deemed to have a complete clinical response. This review discusses the current data as well as the challenges of this approach.