Impact of Negative Prostate-specific Membrane Antigen Positron Emission Tomography on the Decision to Perform a Pelvic Lymph Node Dissection During Radical Prostatectomy for Intermediate- to High-risk Prostate Cancer Patients: Results of an International Survey

Background and objective: Pelvic lymph node dissection (PLND) is considered the most reliable method for managing prostate cancer (PCa). However, the role of PLND remains controversial in both clinical practice and guideline recommendations. This study aims to characterize contemporary practices and attitudes related to extended and/or limited PLND in PCa management during radical prostatectomy (RP). Methods: A cross-sectional survey was conducted from February to May 2025. The survey was disseminated through the official mailing lists of several prominent urological societies worldwide. Multivariable logistic regression models were used to identify the predictors of the performance and perceived benefits of PLND in high-risk PCa patients, considering clinical, institutional, and practitioner-related factors. Key findings and limitations: Our survey of 438 urologists revealed that 80% always perform PLND in European Association of Urology (EAU) high-risk patients during RP, while 18% do so selectively and only 2.6% never do. Among high-risk, prostate-specific membrane antigen (PSMA) positron emission tomography (PET)–negative patients, 53% opt for extended PLND and 39% for standard PLND. The remaining 7.6% either undergo limited/unilateral PLND or do not receive it at all. Notably, only 22% believe in the therapeutic benefit of extended PLND in high-risk PSMA-PET–negative patients, with this proportion increasing to 47% for PSMA-PET–positive cases. The primary rationale for PLND was staging (43%), followed by detecting micrometastases (31%). Multivariable analyses showed that PLND for EAU high-risk patients during RP was independently associated with treatments performed in university/referral centers structured risk stratification following the National Comprehensive Cancer Network guidelines ,and the use of nomograms. Resource limitations, particularly concerns about hospital stays due to complications (58.9%), and reimbursement policy for PLND (30%) impacted PLND practices significantly. Key limitations of the study include a potential selection bias and mainly European responses. Conclusions and clinical implications: Significant variability persists in PLND practices despite evolving guidelines and imaging. Patient summary: Pelvic lymph node dissection (PLND) is a procedure in which lymph nodes are removed and examined during prostate cancer surgery (prostatectomy) to determine whether the cancer has spread. We surveyed urologists worldwide about their current use of this procedure during prostatectomy. The introduction of prostate-specific membrane antigen positron emission tomography scans has changed how doctors decide when to perform PLND. Our findings show considerable variation in practice and persistent uncertainty about its benefits, underscoring the need for further research to guide treatment decisions.