The UroOnc Minute: Pelvic Lymph Node Dissection During Radical Prostatectomy, with Giorgio Gandaglia, MD

Welcome back to The UroOnc Minute!

In this episode of The UroOnc Minute, host Adam B. Weiner, MD, continues Urology Times’ coverage from EAU 2026 in London with guest Giorgio Gandaglia, MD, of San Raffaele Hospital in Milan, Italy, for a focused discussion on one of prostate cancer surgery’s most debated topics: pelvic lymph node dissection (PLND) at the time of radical prostatectomy.¹

Gandaglia outlines why the role of lymph node dissection remains controversial despite years of study. Although contemporary European guidelines have narrowed indications for the procedure, emerging data from randomized trials have suggested that an extended PLND may confer longer-term oncologic benefits in select patients, including possible improvements in clinical recurrence and metastasis-free survival.² At the same time, he emphasizes that many of these studies included heterogeneous patient populations and used end points that continue to fuel debate regarding how broadly the findings should be applied in routine practice.

A central theme of the conversation is patient selection in the era of advanced imaging. Gandaglia explains that while PSMA-PET has improved staging accuracy, negative imaging does not completely exclude microscopic nodal disease, particularly in patients with high-risk features. As a result, some men with apparently localized disease may still harbor occult nodal metastases that could influence prognosis and postoperative management. He highlights the growing importance of multivariable risk models and predictive calculators to better identify which patients are most likely to benefit from nodal dissection while avoiding unnecessary procedures in lower-risk cases.

The discussion also addresses the real-world tradeoffs of surgery. Extended lymph node dissection can increase operative time and raise the risk of bleeding, postoperative complications, and readmissions, making thoughtful decision-making essential. Gandaglia notes that when nodal dissection is pursued, he favors an extended rather than limited template, while cautioning against overinterpreting trials that compared only limited vs extended approaches rather than surgery with or without nodal dissection. He closes by previewing anticipated longer-term data from ongoing studies that may further clarify the therapeutic value of lymph node dissection and help refine counseling for patients undergoing prostatectomy.

REFERENCES

1. Barletta FM, Stabile A, Scuderi S, et al. Assessing the number needed to treat for an extended pelvic lymph node dissection in PSMA-PET negative patients: Contextualizing MSKCC trial findings in the molecular imaging era. Presented at: 41st Annual Congress of the European Association of Urology. London, UK. March 13-16, 2026. Abstract A0548

2. Touijer KA, Vertosick EA, Sjoberg DD, et al. Pelvic Lymph Node Dissection in Prostate Cancer: Update from a Randomized Clinical Trial of Limited Versus Extended Dissection. Eur Urol. 2025;87(2):253-260. doi:10.1016/j.eururo.2024.10.006