The ongoing dilemma in pelvic lymph node dissection during radical prostatectomy: who should decide and in which patients?

Pelvic lymph node dissection (pLND) is considered the most reliable method for the detection of lymph node metastases in prostate cancer. Current clinical guidelines recommend performing pLND in intermediate- and high-risk patients that are defined using different clinical nomograms and different cut-off values. Although the detection of lymph node metastatic disease can identify patients who could benefit from adjuvant therapies and potentially improve prostate cancer-related survival outcomes, so far there has been no level 1 evidence to support this survival benefit. Available retrospective data that suggest oncological benefits are subject to various forms of bias. Furthermore, pLND is not feasible or may be risky in some patient-related conditions, such as morbid obesity and previous history of intraabdominal surgery including organ transplants. In this review, we discuss the current controversies surrounding pLND during robotic-assisted prostatectomy in prostate cancer, specifically the pitfalls in interpretation of restricted evidence suggesting its oncological benefits, and examine the potential influence of patient- and surgeon-related factors that may determine the decision to perform pLND.