Table 1 SWOT (strengths, weaknesses, opportunities, and threats) analysis of extended pelvic lymph node dissection (ePLND) in the Prostate-specific membrane antigen (PSMA) PET era.

• Confirm metastases not detected by imaging (false-negatives)

• Accurate histopathological staging (false-positives)

• Total tumour burden reduction via excision (if nodal metastases present)

• Limitation of anatomical template (missed metastases outside template)

• Limitation of histopathology (may not detect all metastatic cells)

• Associated morbidity/complications, impact on health and quality of life

• Increased intra-operative time

Opportunities

Threats

• Incorporation with PSMA-PET imaging for targeted (Radioguided/Sentinel) LND

• Improved patient selection considering prevalence of metastatic disease (higher nomogram cut-off)

• Absent Level 1 evidence for significant oncological benefit

• Increasing demand on health services to limit low-value care/interventions

• Surgeon proficiency/training

• Earlier use of androgen receptor signalling inhibitors and other medications (pN status less relevant)