Background: Locally advanced rectal cancer poses a persistent challenge due to the risk of local recurrence, which impacts patient outcomes and quality of life. To address this, lateral pelvic lymph node dissection (LPND) has emerged as a surgical approach to improve local control. However, comprehensive studies evaluating the outcomes and patterns of recurrence after LPND are limited. This retrospective study aimed to fill this gap and provide insights into the effectiveness of LPND. Methods: We conducted a retrospective analysis of 515 patients diagnosed with stage II-III lower rectal cancer who underwent TME and LPND between January 2005 and August 2022. Clinicopathological data were collected, and tumor staging followed the TNM classification system. Recurrence patterns, survival rates, and factors influencing lateral pelvic recurrence were assessed. Results: In our cohort, 18.8% of patients had pathologically positive lateral lymph nodes. Patients with lateral lymph node metastasis exhibited significantly lower 5-year relapse-free survival (31.6%) and overall survival (47.8%) rates compared to those without metastasis (69.5% and 84.7%, respectively). Local recurrence occurred in 20.1% of all patients, with 6.7% experiencing lateral pelvis recurrence (LPR) and 17.4% central pelvis recurrence. Multivariate analysis identified age over 75, lateral lymph node metastasis, and adjuvant chemotherapy as independent risk factors for LPR. Conclusions: Lateral pelvic lymph node dissection remains a valuable tool in managing locally advanced rectal cancer. Our findings underscore the importance of surgeon expertise in performing LPND and the potential benefits of combining treatments to further reduce lateral recurrence. LPND should continue to be explored and refined to enhance patient outcomes in this challenging clinical scenario.