Extended pelvic lymph node dissection has long been used during radical prostatectomy to improve staging in men with higher-risk prostate cancer. Whether the more extensive operation also improves cancer outcomes has been less clear.

New long-term randomized data presented at the 2026 American Urological Association Annual Meeting suggest the answer may depend on which patients are being treated.

Jean F.P. Lestingi, MD

In a phase III trial of 300 men with intermediate- or high-risk prostate cancer, extended pelvic lymph node dissection did not improve biochemical recurrence, metastasis-free survival, cancer-specific survival, or overall survival compared with limited dissection in the overall study population. However, among men with preoperative International Society of Urological Pathology (ISUP) grade 3 to 5 tumors, the extended approach was associated with longer biochemical recurrence–free survival and metastasis-free survival.

“This study highlights the importance of personalized decision-making, rather than a one-size-fits-all approach,” said Jean F.P. Lestingi, MD, of Universidade de São Paulo, São Paulo, Brazil.

Study Design and Overall Results

The trial enrolled men with intermediate- or high-risk prostate cancer who were scheduled for radical prostatectomy. Eligible patients had clinical stage T2b or higher disease, a prostate-specific antigen level of at least 10 ng/mL, and/or a Gleason score of 7 or higher. Patients with metastatic disease or prior treatment were excluded.

From May 2012 to December 2016, 300 patients were randomly assigned to undergo either extended or limited pelvic lymph node dissection during radical prostatectomy. Limited dissection included removal of bilateral obturator lymph nodes only. Extended dissection included bilateral obturator, external iliac, internal iliac, common iliac, and presacral lymph nodes.

The primary endpoint was biochemical recurrence–free survival. Secondary endpoints included metastasis-free survival and cancer-specific survival. Mean and median follow-up were 123 and 112 months, respectively.

In the full study population, extended dissection did not provide a significant oncologic advantage over limited dissection. Biochemical recurrence rates were comparable between groups (hazard ratio [HR] = 0.93; P = .681). There were also no significant differences in metastasis-free survival (HR = 0.93; P = .32), cancer-specific survival (HR = 0.97; P = .892), or overall survival (HR = 1.01; P = .988).

High-Grade Subgroup Signal

However, the findings were more encouraging in men with high-grade disease.

Among patients with preoperative ISUP grade 3 to 5 disease, extended dissection was associated with improved biochemical recurrence–free survival (HR = 1.92; P = .034), confirming the benefit previously seen at 5 years, according to the investigators. In the same subgroup, metastasis-free survival was significantly longer with extended dissection (HR = 5.12; P = .035). The numbers needed to treat were 5 for biochemical recurrence–free survival and 4 for metastasis-free survival.

Dr. Lestingi said the finding in patients with more aggressive disease was not explained by greater use of additional treatments such as radiation therapy or hormone therapy. Instead, patients who underwent extended dissection often needed those treatments later, or not at all.

For patients with less aggressive or average-risk disease, removing more lymph nodes during surgery did not appear to provide additional long-term benefit in cancer control or survival, he said. For patients with more aggressive prostate cancer, however, the long-term data suggest that a wider dissection may delay recurrence, reduce the risk of cancer spreading elsewhere in the body, and potentially delay or avoid additional treatment.

Balancing Benefit and Morbidity

The possible oncologic benefit in selected patients has to be weighed against the downsides of a more extensive operation. “Shared decision-making is key,” he said. Patients and clinicians should weigh the potential long-term cancer benefits against longer surgery and a higher risk of mostly minor, temporary side effects, he added.

According to Dr. Lestingi, extended lymph node removal makes the operation longer and technically more complex. It was also associated with more minor complications, especially in the weeks after surgery. These commonly included lymphoceles, or postoperative fluid collections, which may sometimes require treatment.

He concluded that extended lymph node removal “should be considered for select high-risk patients” and that clinical guidelines may need to reflect the long-term results.

Expert Perspective

Adam B. Weiner, MD, a urologic oncologist at Cedars-Sinai, said the overall results support a more selective approach.

“My main takeaway is that extended pelvic lymph node dissection should not be viewed as universally therapeutic for all intermediate- and high-risk patients undergoing radical prostatectomy,” he said. “These long-term data reinforce that the benefit is not broad-based across the entire intermediate- and high-risk population.”

According to Dr. Weiner, the finding in the high-grade subgroup makes clinical sense because patients with high-grade disease are more likely to harbor occult nodal metastases. In those patients, a more comprehensive nodal dissection may be more likely to affect cancer outcomes.

“I would interpret it as a signal that biology matters,” he said. “The overall trial was negative for superiority of extended dissection, but the high-grade subgroup appeared to derive a durable benefit.”

Still, he cautioned against overreading the subgroup result. Subgroup findings, even from randomized trials, need to be interpreted in the context of sample size, confidence intervals, and surgical morbidity, he noted, and extended dissections carry procedural risks, including lymphocele formation, deep vein thrombosis, and leg edema.

Dr. Weiner noted that this trial is not the only randomized study to examine the question. A Memorial Sloan Kettering Cancer Center trial found a metastatic recurrence benefit with extended dissection, including in some lower-risk patients, he noted.

“The practical conclusion is not that every patient needs an extended dissection, and it is not that extended dissection has no role,” Dr. Weiner said. “Rather, the benefits may be limited to patients with higher-grade, higher-risk biology.”

In practice, clinicians should consider grade group, PSA level, clinical stage, MRI findings, biopsy volume, nomogram-predicted nodal risk, and patient comorbidity when deciding how extensive lymph node removal should be, he advised. Current U.S. and international guidelines generally support a risk-based approach, and tend to agree that when lymph node dissection is performed, an extended approach should be considered for improved staging. 

DISCLOSURE: Drs. Lestingi and Weiner reported no relevant conflicts of interest.

REFERENCE

1. Ruggeri MT, Pontes J Jr, Guglielmetti GB, et al: Long-term oncological outcomes of extended versus limited pelvic lymph node dissection during radical prostatectomy for intermediate- and high-risk prostate cancer: Phase III randomized clinical trial. Presented at the 2026 American Urological Association Annual Meeting; Washington, DC. Abstract 26-4965.