Background: In the surgical therapy of rectal cancer, the clinical and prognostic importance of the lateral pelvic lymph node (LPLN) compartment is still up for debate. The typical surgical treatment for rectal cancer is total mesorectal resection. MRI can be considered as a reliable tool to evaluate LPLN involvement, so surgery can extend to include lateral pelvic lymph node dissection (LPLND) in addition to the standard treatment. Objectives: The aim of the current study was to correlate between preoperative radiological status of pelvic lymph nodes in rectal cancer and post-operative histopathology. Methods: The study included 20 patients with middle and low rectal cancer with evident pelvic lymph node enlargement on preoperative MRI. All the included patients were subjected to surgical resection (either upfront surgery or after neoadjuvant therapy). Postoperative pathological data were analyzed and correlated to the preoperative radiological status of pelvic lymph nodes. Results: The most common presentation was bleeding per rectum (50%) followed by pain (30%) then constipation (20%). The most common pathological type among study group was adenocarcinoma (80%) while mucinous carcinoma was encountered in (20%) of the patients. Postoperative pelvic lymph node involvement was found in 65% of the cases with a false positive rate of 35%. Their involvement was significantly related to increased depth of tumor invasion (T3 and T4) (p=0.009) with a significant longer hospital stay (p < 0.001 Conclusions: Due to the increased likelihood of lateral lymph node involvement in T3-T4 lower rectal cancer patients, LPLND may be recommended.