Pelvic lymph node dissection (PLND) during radical prostatectomy has historically been recommended for staging purposes and a potential oncological benefit. Extended PLND (ePLND) provides more accurate staging, detecting more lymph node (LN) metastases than limited PLND (lPLND). This information helps guide postoperative counselling and consideration of adjuvant therapies. However, randomised trials have not demonstrated a clear survival benefit. Studies by Lestingi and Touijer et al. found higher detection rates with ePLND but no difference in biochemical recurrence, with ePLND associated with higher complication rates. PSMA PET/CT has emerged as a non-invasive staging tool with high specificity, detecting more metastases than conventional imaging and even some beyond standard dissection templates. While PSMA PET/CT improves risk stratification, it can miss micrometastases below 5mm. Patients with PSMA-positive nodal disease (miN1) often have worse outcomes and may benefit from intensified treatment. ePLND carries considerable morbidity, including lymphocele formation, thromboembolic risk, and higher rates of lymphoedema, particularly when combined with radiotherapy. Long-term quality of life can be significantly affected. Nomograms integrating clinical and imaging data, including PSMA PET/CT, allow individualised ePLND decision-making. Patients with low risk and negative PSMA scans may safely avoid ePLND. In contrast, high-risk patients with negative imaging might still harbour micrometastases and could be considered for ePLND or upfront radiotherapy strategies. In 2024, the European Association of Urology (EAU) downgraded its recommendation for ePLND due to lack of proven therapeutic benefit and increased morbidity. With the adoption of PSMA PET/CT, the balance of risk and benefit has shifted. The decision to perform ePLND should now involve shared decision making, taking into account individual risk profiles and patient preferences, adhering to the principle of ‘first, do no harm’.
Why perform PLND?
Reviewed by Asif H Ansari
Pelvic lymph node dissection in prostate cancer: evidence and implications.
