BACKGROUND: The safety and feasibility of laparoscopic surgery for the management of rectal gastrointestinal stromal tumors are unknown. OBJECTIVE: This study aimed to compare the surgical and oncologic results of laparoscopic versus open surgery for the treatment of rectal gastrointestinal stromal tumors. DESIGN: This was a retrospective multicenter propensity score-matched study to minimize heterogeneity between groups and focus on the difference between surgery strategies. SETTINGS: Eleven Chinese tertiary hospitals participated in this study. PATIENTS: A total of 364 patients with pathologically confirmed rectal gastrointestinal stromal tumors were retrospectively analyzed. MAIN OUTCOME MEASURES: Relapse-free survival, postoperative hospital stay length, and 30-day postoperative complication rate were the main outcome measures. RESULTS: We enrolled 214 patients who underwent surgical operation for primary localized rectal gastrointestinal stromal tumors. After propensity score matching, 134 cases involved in the comparison (67 laparoscopic vs 67 open surgery) were randomly matched (1:1) by sex, age, tumor size, tumor site, and neoadjuvant therapy. The laparoscopic surgery group had superior relapse-free survival (chi(2) = 4.46, p = 0.04), and fewer complications (6.0% vs 25.4%, p = 0.002). No significant difference was found in the length of postoperative hospital stay between the laparoscopic surgery and open surgery groups (9.66 +/- 5.42 vs. 10.64 +/- 4.93, p = 0.28). Subgroup analysis showed that the laparoscopic surgery group had superior relapse-free survival (chi(2) = 4.14, p = 0.04) and fewer complications after surgery (2.9% vs 24.4%, p = 0.01) in the rectal gastrointestinal stromal tumors <= 5 cm subgroup. LIMITATIONS: This study was limited by the nature of retrospective reviews and relatively short follow-up period. CONCLUSIONS: Laparoscopic surgery offers a safe and feasible option for the radical resection of primary localized rectal gastrointestinal stromal tumors, especially for patients with rectal gastrointestinal stromal tumors <= 5 cm.