EDITORIAL COMMENT

The role of pelvic lymph node dissection (PLND) in radical prostatectomy remains controversial. Historically, the grossly node-positive disease was a contraindication for radical prostatectomy, while today, multiple studies have reported a possible survival benefit of removing that nodal disease. The diagnostic utility of PLND is well established by the many studies that have shown greater lymph node yields from a PLND result in a higher incidence of nodal disease. However, the therapeutic benefit of PLND remains unknown due to the limitations of retrospective studies and the lack of universally accepted criteria on patient selection and extent of dissection. We applaud the authors for mitigating some of these limitations by directly comparing patients who were upstaged and would have gotten a PLND based on final pathology to a matched cohort of patients who did undergo PLND. The authors clearly show that performing a PLND does not alter a patient's clinical course regarding receiving adjuvant treatment or biochemical recurrence rates. This finding was confirmed on multivariate analysis with nodal status not being associated with biochemical recurrence. PSA is an easy and effective way to monitor recurrence, and the literature has shown that early salvage treatments are as effective as adjuvant treatments. Thus, if performing a PLND does not decrease a patient's risk of biochemical recurrence and positive nodal disease is not predictive of biochemical recurrence, it is time to ask whether PLND during radical prostatectomy is worth the increased cost and risk of morbidity. In answering this question, we eagerly await the completion of clinical trials such as NCT03921996 that compare the outcomes between foregoing versus carrying out extended lymph node dissections during radical prostatectomy.