Total neoadjuvant therapy does not change the selection criteria for lateral pelvic lymph node dissection in rectal cancer.

• 25% of patients undergoing lateral pelvic lymph node dissection had pathologically positive nodes.
• Key risk factors for positive nodes include CT4b stage (odds ratio 2.60) and multiple enlarged lymph node stations (odds ratio 3.82).
• Three-year local recurrence-free survival rates were comparable: 90% for total neoadjuvant therapy and 85% for long-course chemoradiotherapy.

Surgeons can use existing selection criteria without modification regardless of the neoadjuvant therapy approach.