PSMA PET/CT-guided pelvic lymph node dissection in patients with unfavorable intermediate- or high-risk prostate cancer.

[OBJECTIVES] PSMA PET/CT (Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography) offers improved accuracy in detecting lymph node invasion (LNI) in prostate cancer (PC) patients, potentially reducing the need for extended pelvic lymph node dissection (ePLND). This study aims to evaluate a patient-tailored care pathway in which ePLND is performed only in patients with unfavorable intermediate- or high-risk PC who are deemed at risk for LNI based on PSMA PET/CT findings.

[METHODS] In this interventional cohort study, 81 patients were managed according to the new care pathway. ePLND was omitted in cases of negative PSMA PET/CT findings (N0M0), while those with positive PSMA PET/CT findings (N1M0) underwent ePLND. A comparator group of 81 patients was selected from a prospectively generated database for comparison.

[RESULTS] The intervention group experienced a 75% reduction in the number of ePLNDs performed compared to the comparator group (p < 0.001). ePLND-related complications were significantly lower in the intervention group (p = 0.008). No significant difference was observed in 3-year biochemical-recurrence free survival (BRFS) between the two groups (p = 0.958).

[CONCLUSION] Omitting ePLND in patients with negative PSMA PET/CT findings (N0M0) leads to a substantial reduction in the number of ePLNDs performed, resulting in a decrease in morbidity, without compromising early oncological outcomes.