The utility of pelvic lymph node dissection in PSMA-PET negative intermediate and high-risk prostate cancer patients undergoing radical prostatectomy.

To compare perioperative and early oncological outcomes of robotic radical prostatectomy (RP) with and without extended pelvic lymph node dissection (PLND) in a cohort of intermediate (IR)-to-high-risk (HR) prostate cancer (PCa) patients. Data was prospectively collected from 88 patients (47 PLND, 41 no-PLND) with unfavorable intermediate- and high-risk miN0M0 PCa, all staged preoperatively with PSMA-PET/CT. Outcomes were assessed using Kaplan-Meier curves, uni-and multivariable Cox regression, for biochemical recurrence-free survival (BCRFS) and biochemical failure-free survival (BCFFS). A propensity score matched analysis with Cox regression was undertaken matching 1:1 for potential confounders (age, iPSA, preoperative ISUP, cT stage at MRI). Both groups (PLND and no-PLND) had the same proportion of HR patients (p = 1.0). The no-PLND group had a shorter median operative time by 50 min (p < 0.01). Conversely, the PLND group experienced significantly higher rates of 90-day high-grade complications (p = 0.03) and lymphoceles (p < 0.01). Over a median 20.5-month follow-up, no significant differences emerged in BCRFS (p = 0.59) or BCFFS (p = 0.76). Uni- and multivariable analyses adjusted for UCSF CAPRA and CAPRA-S variables, as well as propensity score matching, confirmed PLND was not associated with improved BCFFS. In patients who did recur, the sites of recurrence did not differ between the two groups (p = 0.62), with pelvic nodal recurrence being the most common site of recurrence in both groups (6, 50% for PLND and 3, 60% for no-PLND). In this short-term follow-up, performing PLND increased high-grade postoperative complications without providing a clear early oncological benefit regarding BCRFS, PSA persistence, or recurrence location.