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In the context of minimizing local recurrence rates after surgical treatment of rectal cancer, the issue of lateral pelvic lymph node (LPLN) dissection has remained as a controversial issue between West and East surgeons. The aim of the present paper was to review the incidence of lateral nodes, the associated risk factors and all the controversies regarding their management. While in Japan a prophylactic LPLN removal with autonomic nerve preservation (without neoadjuvancy) is considered the standard management of extra-peritoneal advanced rectal cancers, Western patients are usually treated with preoperative chemoradiotherapy (CRT) followed by total mesorectal excision. This choice is based on the effective reduction of local recurrences induced by CRT, culminating with similar outcomes when compared with LPN dissection. On the other side, this procedure is currently performed in Japan where LPN involvement is considered regional disease, so LPLN dissection is considered essential to improve outcomes. There exist suggestions that a selective approach to lateral nodes could be safely adopted in patients exhibiting radiological response after neoadjuvancy. However, others think that a more extended procedure is necessary even after CRT. Thus, the source and the risks of local recurrence must be individually assessed, and further high quality investigations must be developed to evaluate the efficacy of LPLN dissection with or without CRT.