Background:  there a conflicting results about the best approach of management of rectal cancer with lateral lymph nodes metastases and the role of performing lateral pelvic lymph nodes dissection in addition to total mesorectal excision in rectal cancer patient in improving patients' oncological outcomes is still uncertain. Aim of the study was to correlate between performing lateral lymph nodes dissection in addition to total mesorectal excision and performing total mesorectal excision alone with neo-adjuvant therapy in patients with low rectal cancer. Patients and methods: all patients with histologically confirmed low cancer rectum stages II and III, located below the level of the peritoneal reflection, aged from 20-85 years with no previous chemo-radiotherapy or pelvic surgery. We randomly divided patients who met the inclusion criteria into 2 groups the first group underwent total mesorectal excision in addition to lateral lymph nodes dissection while the second group underwent only total mesorectal excision alone with neo-adjuvant therapy. Operative, perioperative and oncological outcomes were assessed. Results: we showed that the operative time of total mesorectal excision in addition to lateral lymph node dissection was longer and resulted in more blood loss than total mesorectal excision only (p<0.001). Local recurrence rates (p=0.008 and 0.022), disease free survival rates (p= 0.27) and overall survival rates (p=0.047 and 0.001) were more favorable in patients underwent total mesorectal excision and lateral pelvic lymph nodes dissection than patients underwent total mesorectal excision alone.  Conclusions: for patients with advanced low cancer rectum total mesorectal excision and lateral pelvic lymph nodes dissection decreased incidence of local recurrence and improved patients' survival than total mesorectal excision only.