There has historically been a significant divide in the approach to the management of lateral pelvic lymph nodes in patients with rectal cancer. These differing paradigms have developed based upon competing priorities. In the West, the circumferential resection margin has been the main focus because it is a strong predictor of local recurrence, distal recurrence, and survival. This approach was supplemented by radiation and chemotherapy to treat the lateral pelvic lymph nodes and micrometastatic disease. In the East, lateral pelvic lymph nodes are considered to be locoregional; thus, surgical treatment has traditionally included routine dissection of this compartment for low rectal cancers without the use of neoadjuvant chemoradiotherapy. However, neither approach has adequately addressed the important issue of lateral compartment recurrence in patients with clinically evident lateral pelvic lymph node metastasis. The aims of the review were to present the recent key studies and evolution of lateral pelvic lymph node management in locally advanced rectal cancer and secondly to propose a management strategy for the lateral compartment based on the current evidence.