Background and Aims There is currently a lack of clinical experience in using the natural orifice robot-assisted transanal total mesorectal excision (NOSES R-taTME) approach to treat "difficult pelvic" low rectal cancer. Therefore, this study summarizes and analyzes the clinical data of three patients who underwent this procedure, evaluates short-term results, and aims to provide preliminary experience for clinical practice.Methods The perioperative data and short-term outcomes of three patients with "difficult pelvic" low rectal cancer who underwent NOSES R-taTME treatment at the First Affiliated Hospital of Zhengzhou University from February to May 2022 were retrospectively analyzed.Results All three patients were male, aged 54-59 years, and the BMI was 24-34 kg/m². The distance between the ischial tuberosities was 8.0-9.5 cm, the distance from the tumor to the anal verge was 4-5 cm, and a mesorectal fat area of 23.1-30.7 cm². One patient received neoadjuvant chemotherapy, and two patients had tumors located on the anterior wall of the rectum. The robot docking time was 9-20 min, the transanal operation time was 40-70 min, the total operation time was 200-290 min, the estimated blood loss was 50-100 mL, and the total number of lymph nodes retrieved was 15-20. All three cases achieved R₀ resection, and complete total mesorectal excision grade. Postoperative pathology showed stage I in two cases and stage Ⅲ in one case. The length of postoperative hospital stay was 7-11 d All operations were completed successfully without conversion to open surgery, postoperative complications, or deaths, and there were no unplanned readmissions within 30 d after surgery. During follow-up for 3 months, no anastomotic-related complications were observed, and there was no evidence of tumor recurrence or metastasis.Conclusion The NOSES R-taTME approach is safe and feasible for the treatment of "difficult pelvic" low rectal cancer. However, this conclusion still requires further confirmation through larger prospective studies.