Purpose The rate of organ preservation in patients with rectal cancer is increasing worldwide. This is likely due to the adoption of a watch and wait (W&W) approach in patients with a complete clinical response following neoadjuvant therapy. Despite widespread use, data on outcomes in Australasia is lacking. The aim of this study is to investigate outcomes associated with W&W in Aotearoa New Zealand (AoNZ). Methodology A retrospective, national cohort study of patients managed with W&W between January 2015 and December 2022 in AoNZ was performed. This study was run by STRATA, a student- and trainee-led collaborative. The Cancer Registry and the National Minimum Data Set were linked to identify a longlist of patients who had rectal cancer, received neoadjuvant therapy, but had not had a colonic resection. Mini research teams in 17 hospitals across AoNZ then screened this longlist of patients for inclusion and data collection. Results 1505 patients were screened. 132 were included. Mean age was 70.5, 36% were female, 76% were NZ European, and 6% were Māori. Median follow up was 1.9 years. 2-year cumulative incidence of local regrowth was 17.5%(95%CI 10.0-24.4%). 91.7% of regrowth was present in the bowel wall. 70.8% of patients with local regrowth underwent surgery, all with curative intent. Distant metastasis rate was 8.4% at a median 1.3 years. 2-year overall survival was 92.9% (95%CI 87.4-98.8%). Conclusion This is the first study to investigate the use of the W&W approach in AoNZ. Clinical outcomes were in keeping with international studies, with acceptable rates of local regrowth and excellent overall survival. This data will help guide clinicians and inform patients in AoNZ.