Is pelvic lymph node dissection still necessary in the era of PSMA PET imaging? In this episode of BackTable Urology, Dr. Ruchi Talwar interviews Dr. Kirsten Greene about how advanced imaging is influencing decisions for radical prostatectomy. They examine the strengths and limits of PSMA PET, the risks and benefits of PLND, and why careful, evidence-based decision-making remains essential.

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Timestamps

00:00 - Introduction
03:12 - Risk Calculators and Consent
04:39 - Nomograms vs. Complications
09:57 - Endpoints That Matter
11:38 - PSMA PET Strengths and Limits
13:51 - Negative PET Decision-Making
15:08 - Positive PET and Multimodal Care
18:02 - Fluorescence Guided Surgery
19:10 - Counseling on Complications
22:27 - Preventing Lymphocele
24:56 - How Lahey Wrap Works
26:45 - Future Mapping and Therapy
28:47 - Research Gaps and Dogma
31:07 - Key Pearls and Wrap Up

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More about this episode

Dr. Greene explains her approach using MSK and Briganti nomograms alongside PSMA PET, noting that PET scans may miss small nodal disease and quality varies between centers. She emphasizes PLND as a staging tool rather than a curative procedure, outlining potential complications like lymphocele, lymphedema, vascular and ureteral injury, and neuropraxia. The episode highlights her shared decision-making process, surgical techniques for limiting risk, and the importance of multimodal planning, especially for PET-positive nodal disease. Dr. Greene also shares practical tips for lymphocele prevention, including the use of metal clips and the Lahey wrap.

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Resources

Different lymph node dissection ranges during radical prostatectomy for patients with prostate cancer: a systematic review and network meta-analysis
https://pubmed.ncbi.nlm.nih.gov/36872312/

Limited versus Extended Pelvic Lymph Node Dissection for Prostate Cancer: A Randomized Clinical Trial https://pubmed.ncbi.nlm.nih.gov/33865797/

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