This report describes the case of a 61 years old woman, with a well differentiated adenocarcinoma of the lower rectum. The lesion was initially classified as cT4a cN0 cM0, measuring 5 cm at the cephalo-caudal axis; distant 1cm of the anal sphincter; and classified as York-Masson IIIb. The patient was referred to neoadjuvant Chemoradiotherapy, with the description of partial response of more than 50%. However, the patient initially refused surgical treatment for ten months. After that, the patient returned with severe anal bleeding and paradoxal incontinence. The patient was submitted to a new clinical workup, with the following restaging: cyT4b cyN0 cM0. The primary tumor, had grown, and it invaded the pre-sacral fascia at the level of S4-S5; as well as the lower sacrum at the level of S5, and the coccyx. Then the patient was referred, and accepted for surgical treatment, the en-block Extralevator abdominoperineal excision, with en block lower sacral resection at S3-S4. The ventral approach was performed through laparoscopy until the point of tumor invasion at the sacrum. After that, ressection continues through prone position. Surgery occurred with minimal blood loss, with no need of intensive care, and a total hospital stay of four days. Anatomo-pathologic findings corroborated the preoperative diagnostic (Adenocarcinoma G-I), as well as it's staging, ypT4b ypN0 ycM0. Patient remains disease free after 18 months, after surgery.