Total mesorectal excision and neoadjuvant radio-chemo-therapy is the standard treatment of locally advanced rectal cancer. In 4-12% of all patients a local recurrence will develop, with more than half located on the lateral pelvic side wall. It is an ongoing controversy, whether malignant lateral pelvic lymph nodes should be considered as regional or distant disease. The role of lateral pelvic lymph node dissection in a Western treatment setting is not clarified, but in this review, we argue that it may reduce the risk of local recurrence in selected patients with locally advanced disease.