Dissect correctly.

No one is very sure what to do with men who present with node-positive prostate cancer. Not even NCCN guidelines. Enter this large retrospective review of prospectively maintained databases of men receiving radical prostatectomy for prostate cancer at three institutions in Italy, Belgium, and the one and only Mayo-Rochester. Of almost 24K cases included, a grand total of 162 with upfront radiographic evidence of nodal involvement were identified—hence the unsureness in management. It probably goes without saying that all these men underwent dissections of pelvic (80%) and, when involved, retroperitoneal (20%) nodes. The primary endpoint of recurrent metastatic (including nodal) disease occured in 59% within 8 years. However that rate was <10% among those with grade group 1-3 disease and ≤2 nodes involved, much in line with predictors of benefit with salvage node dissection. Of note, only a small minority received adjuvant (17%) or salvage (14%) radiation. TBL: Not all nodal prostate cancer is created equal, and those with lower Gleason scores may achieve excellent outcomes with surgical management. | Gandaglia, Eur Urol 2019