Rectal cancer constitutes a major public health issue. Total mesorectal excision has remained the gold standard treatment for mid and low rectal tumors since its introduction in the late 1980s. Removal of all lymph nodes located in the mesorectum has indeed improved pathological and oncological outcomes. However, when cancer spreads to the lateral lymph nodes (located along the iliac and obturator arteries) Western and Japanese practices differ. Where the Western guidelines consider this condition as an advanced form of the disease and use neoadjuvant radiochemotherapy liberally, the Japanese guidelines define it as a local disease and proceed to lateral lymph node dissection with or without neoadjuvant treatment. Herein, we review the current literature regarding both therapeutic strategies, with the aim of contributing to potential improvements in treatment and outcome for patients with low and mid rectal cancer.