Rectal cancers often fail locally because of metastasis to the lateral pelvic lymph nodes (LPLN), which can be treated. The purpose of this study was to assess clinical and oncological outcomes after total neoadjuvant therapy (TNT) in patients who underwent magnetic resonance imaging (MRI)-guided surgical selection for lateral pelvic lymph node dissection (LPLND). Pretreatment MRI showed an increased LPLN in patients with rectal cancer, hence a retrospective sequential cohort analysis was done on these individuals. Both LPLND and non-LPLND patients were considered. Rates of perioperative and oncological complications, as well as parameters related to LPLND decision-making, were the primary endpoints. About 138  patients were found to have TNT therapy for increased LPLN before treatment. Around 20  months of follow-up was the median (interquartile range 10–32). LPLND was performed on 88 individuals (56.0%) after a multidisciplinary assessment. The average age was 53 (SD±12) years, and 54 of the participants (34.2%) were female. Even though the LPLND group had a longer total operative time (509 vs. 429 minutes; P=0.003) and a higher rate of significant morbidity (19.3% vs. 17.0%), there was no difference in median blood loss (P=0.70). In 34.1% of cases, pathology was positive for LPLNs. The 3-year lateral local recurrence rates did not vary significantly between the 2 groups (3.4% vs. 4.6%; P=0.85). Patients with LPLNs that were heterogeneous and had an irregular margin before treatment were more likely to suffer LPLND (odds ratio, 3.82; 95% CI, 1.65-8.82) or have a short axis more than equal to 5 mm after TNT (odds ratio, 2.69; 95% CI, 1.19-6.08). There is no significant difference in perioperative or oncologic outcomes when using a multidisciplinary MRI-directed approach to select patients for LPLND in patients with rectal cancer who have evidence of LPLN metastases.