Lateral pelvic lymphadenectomy is routinely performed in advanced lower rectal cancers by Japanese surgeons, whereas in the western world it has not progressed to a frequently performed technique. Claimed benefit for this extensive surgery is an improved locoregional control; on the other hand, low positive lateral lymph node yields, questionable prognostic significance, and high morbidity (urinary and sexual dysfunction) are main reasons against this procedure. Clinical results published on lateral lymphadenectomy in the literature are conflicting. Due to major improvements in local control and survival of rectal cancer patients mainly based on preoperative radiotherapy and total mesorectal excision (TME), only a few patients may profit from lateral lymph node dissection. This article gives an overview of the current status and the clinical relevance of the lateral lymph node compartment in rectal cancer surgery.