ObjectiveTo analyze the relation between preoperative staging and surgical decision-making in rectal cancer patients from the West China Colorectal Cancer Database (DACCA) and to identify key factors influencing the selection of surgical approaches. MethodsBased on the updated DACCA dataset as of April 24, 2024, the patients with rectal cancer were included. Chi-square tests and logistic regression analyses were performed to evaluate the correlation between preoperative staging [(y)cTNM stage] and the selection of sphincter-preserving surgery or intersphincteric resection (ISR). Additional factors, including age, body mass index (BMI), tumor location, and nutritional score, were assessed for their impact on surgical choices. ResultsA total of 2 733 rectal cancer patients were included. Preoperative (y)cTNM staging distribution was as follows: Stage 0 (0.8%, n=23), stageⅠ (14.2%, n=388), stage Ⅱ (27.8%, n=760), stage Ⅲ (31.9%, n=873), and stage Ⅳ (25.2%, n=689). Advanced preoperative staging (Stages II–IV) was independently associated with non–sphincter-preserving surgery (Stage II: OR=0.073; Stage III: OR=0.068; Stage IV: OR=0.039; all P<0.001). Low/ultralow rectal tumors were a risk factor for sphincter preservation failure (OR=0.491, 95% CI: 0.358–0.672) but significantly increased ISR utilization (OR=76.658, P<0.001). Nutritional scores of 4 (OR=0.261) and 6 (OR=0.098) correlated with reduced ISR implementation (both P<0.05). ConclusionsPreoperative staging serves as the cornerstone for surgical decision-making in rectal cancer, with advanced stages favoring non–sphincter-preserving and non-ISR approaches. While low/ultralow tumors challenge sphincter preservation, ISR remains a predominant option. Tumor anatomy and nutritional status critically influence surgical strategy, necessitating comprehensive preoperative evaluation.