Background and Objectives: To determine retrospectively in a population-based setting, the influence of the introduction of total mesorectal excision (TME) on local recurrence and survival in patients with rectal carcinoma. Methods: All rectal carcinomas diagnosed during 1988-1991 (979 patients, conventional surgery with blunt dissection of the rectum) and 1998-2000 (890 patients, TME resection) were selected from the Amsterdam Cancer Registry. For all patients who underwent a macroscopically radical resection in the absence of distant dissemination, information on the occurrence of local recurrent disease and distant metastasis was collected. Results: The cumulative 5-year recurrence rate decreased significantly from 20% for patients diagnosed in 1988-1991 to 11% in 1998-2000. Stage (T-category, nodal status), period of diagnosis (conventional surgery vs. TME resection), radiotherapy, and chemotherapy were independent variables of local recurrence in multivariate analysis. There was a non-significant trend for improved 5-year relative survival for all rectal carcinoma cases from 52% (95% CI 48-55) for patients diagnosed in 1988-1991 to 59% (95% CI 55-63) in 1998-2000. Conclusions: A significant decrease in local recurrence and a trend for improved relative survival were observed. The broad introduction of TME and the shift towards preoperative radiotherapy are the most plausible explanations for these observations.