Pelvic lymph node management in prostate cancer: a narrative review

Pelvic lymph node management plays an important role in the staging and treatment of early prostate cancer, especially for higher risk patients. This narrative review explores the current practices and emerging techniques, including advanced imaging, surgical techniques, and radiotherapeutic strategies. The introduction of prostate-specific membrane antigen (PSMA) positron emission tomography/ computed tomography (PET/CT) has revolutionized nodal staging, offering improved diagnostic accuracy compared to conventional imaging modalities. However, pelvic lymph node dissection (PLND) remains the gold standard, albeit with significant morbidity and uncertain survival benefits due to its invasive nature. Less invasive approaches, such as sentinel lymph node biopsy and radioguided surgery, are promising techniques which aim to reduce procedural morbidity, while maintaining a reasonable standard of staging accuracy. We also explored the role of extended lymph node dissection (ePLND), which suggests potential oncological benefits in selected patients. Additionally, advancements in radiation therapy, including whole-pelvic irradiation guided by predictive risk scores offer alternative modalities for managing node-positive disease. However, the current heterogeneity in clinical protocols and outcomes highlights the need for more standardization and robust comparative studies. This review highlights the evolving paradigm of pelvic lymph node management, advocating for personalized approaches that integrate molecular imaging and emerging technologies to optimize outcomes for prostate cancer patients.