Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Can pelvic lymph node dissection be spared in intermediate-risk prostate cancer patients with negative PSMA PET scan? A systematic review and diagnostic meta-analysis

Prostate Cancer and Prostatic Diseases (2026)Cite this article

Subjects

Abstract

Objective

The aim of this study was to meta-analyze published data on the diagnostic performance of PSMA PET/CT in detecting lymph node invasion (LNI) in intermediate-risk prostate cancer (PCa) patients, and to discuss whether pelvic lymph node dissection (PLND) can be spared in patients with negative PSMA PET scan.

Patients and methods

The PubMed and Embase databases were searched through November 2025 to identify relevant articles. Methodological quality of each study was assessed. Patient-based sensitivity and specificity were pooled using the bivariate random-effects model. Patient-based negative predictive value (NPV) was pooled using the DerSimonian-Laird model. Histopathology from PLND and clinical follow-up served as the reference standard.

Results

Twelve eligible studies, comprising a total of 1619 patients with intermediate-risk PCa, were included. Overall, the studies were of moderate methodological quality. The sensitivity and specificity of PSMA PET/CT for the detection of LNI ranged from 0% to 100% and from 87% to 99%, respectively, with pooled estimates of 49% [95% confidence interval (CI) 27–72%] and 95% (95% CI 93–97%), respectively. The NPV of PSMA PET/CT for the detection of LNI ranged from 74% to 100%, with pooled estimates of 95% (95% CI 91–98%).

Conclusion

This meta-analysis of current diagnostic evidence suggests that intermediate-risk PCa patients with negative PSMA PET scan may omit PLND at the time of radical prostatectomy. However, the moderate sensitivity of PSMA PET and the associated risk of missing micrometastatic disease underscore the need for cautious application and shared decision-making. Further large-scale prospective validation studies and future follow-up results focusing on the clinical outcomes of these patients will lend stronger support to this approach.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to the full article PDF.

USD 39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Diven MA, Tshering L, Ma X, Hu JC, Barbieri C, McClure T, et al. Trends in Active Surveillance for Men With Intermediate-Risk Prostate Cancer. JAMA Netw Open. 2024;7:e2429760.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Eraky A, Tillu N, Ben-David R, Hug B, Jodka H, Agarwal Y, et al. Diagnostic Accuracy of [(18)F]-DCFPyL Prostate-Specific Membrane Antigen Positron Emission Tomography/Computerized Tomography in Intermediate-Risk Prostate Cancer Undergoing Radical Prostatectomy: Is Pelvic Lymph Node Dissection Still Necessary? J Urol. 2025;214:365–73.

    Article  PubMed  Google Scholar 

  3. Flammia RS, Hoeh B, Chierigo F, Hohenhorst L, Sorce G, Tian Z, et al. Differences in rates of pelvic lymph node dissection in National Comprehensive Cancer Network favorable, unfavorable intermediate- and high-risk prostate cancer across United States SEER registries. Curr Urol. 2022;16:191–6.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Stabile A, Pellegrino A, Mazzone E, Cannoletta D, de Angelis M, Barletta F, et al. Can Negative Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Avoid the Need for Pelvic Lymph Node Dissection in Newly Diagnosed Prostate Cancer Patients? A Systematic Review and Meta-analysis with Backup Histology as Reference Standard. Eur Urol Oncol. 2022;5:1–17.

    Article  PubMed  Google Scholar 

  5. Song D, Malshy K, Messing EM, Joseph JV, Bandari J. Excluding PLND in favourable intermediate-risk prostate cancer: a PSMA-PET-directed perspective. Nature Rev Urol. 2025;13:6534.

  6. Orsini A, Cicchetti R, Digiacomo A, De Archangelis R, Basconi M, Litterio G, et al. Avoiding pelvic lymph node dissection in intermediate-risk prostate cancer with negative PSMA PET: a step toward personalized surgery. Minerva Urol Nephrol. 2025;77:422–4.

    Article  PubMed  Google Scholar 

  7. Zattoni F, Carletti F, Reitano G, Novara G, Dal Moro F. PSMA PET vs. surgery: redefining lymph node staging in prostate cancer. Minerva Urol Nephrol. 2024;76:785–7.

    PubMed  Google Scholar 

  8. Morizane S, Takenaka A. Current status and therapeutic value of extended pelvic lymph node dissection during radical prostatectomy for prostate cancer. Prostate Int. 2024;12:117–27.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Preisser F, van den Bergh RCN, Gandaglia G, Ost P, Surcel CI, Sooriakumaran P, et al. Effect of Extended Pelvic Lymph Node Dissection on Oncologic Outcomes in Patients with D’Amico Intermediate and High Risk Prostate Cancer Treated with Radical Prostatectomy: A Multi-Institutional Study. J Urol. 2020;203:338–43.

    Article  PubMed  Google Scholar 

  10. Carll J, Shi W, Perera M, Lawrentschuk N, Chengodu T, Woon D. Guideline of guidelines: PSMA PET in staging newly diagnosed intermediate-risk prostate cancer. BJU Int. 2025;136:800–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Hofman MS, Lawrentschuk N, Francis RJ, Tang C, Vela I, Thomas P, et al. Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study. Lancet. 2020;395:1208–16.

    Article  CAS  PubMed  Google Scholar 

  12. Chow KM, So WZ, Lee HJ, Lee A, Yap DWT, Takwoingi Y, et al. Head-to-head Comparison of the Diagnostic Accuracy of Prostate-specific Membrane Antigen Positron Emission Tomography and Conventional Imaging Modalities for Initial Staging of Intermediate- to High-risk Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol. 2023;84:36–48.

    Article  PubMed  Google Scholar 

  13. Lenis AT, Pooli A, Lec PM, Sadun TY, Johnson DC, Lebacle C, et al. Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Compared with Conventional Imaging for Initial Staging of Treatment-naïve Intermediate- and High-risk Prostate Cancer: A Retrospective Single-center Study. Eur Urol Oncol. 2022;5:544–52.

    Article  PubMed  Google Scholar 

  14. Kopp D, Kopp J, Bernhardt E, Manka L, Beck A, Gerullis H, et al. 68Ga-Prostate-Specific Membrane Antigen Positron Emission Tomography-Computed Tomography-Based Primary Staging and Histological Correlation after Extended Pelvic Lymph Node Dissection in Intermediate-Risk Prostate Cancer. Urol Int. 2022;106:56–62.

    Article  CAS  PubMed  Google Scholar 

  15. Bauckneht M, Checcucci E, Lanfranchi F, Cisero E, Rizzo A, Scuderi S, et al. The added value of PSMA PET to nomograms in identifying optimal candidates for extended pelvic lymph node dissection in intermediate-risk prostate cancer patients. Minerva Urol Nephrol. 2025;77:639–46.

    Article  PubMed  Google Scholar 

  16. Incesu RB, Preisser F, Nohe F, Maurer T, Graefen M, Tilki D. Negative PSMA PET can be used to avoid unnecessary pelvic lymph node dissection in intermediate risk prostate cancer. Prostate Cancer Prostatic Diseases 2025;28:874–8.

  17. Evangelista L, Guglielmo P, Giacoppo G, Setti L, Aricò D, Muraglia L, et al. The Evaluation of Radiolabeled Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography for Initial Staging in Intermediate-Risk Prostate Cancer Patients: A Retrospective Multicenter Analysis. Diagnostics 2024;14:2751.

  18. Briganti A, Larcher A, Abdollah F, Capitanio U, Gallina A, Suardi N, et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol. 2012;61:480–7.

    Article  PubMed  Google Scholar 

  19. Salameh JP, Bossuyt PM, McGrath TA, Thombs BD, Hyde CJ, Macaskill P, et al. Preferred reporting items for systematic review and meta-analysis of diagnostic test accuracy studies (PRISMA-DTA): explanation, elaboration, and checklist. BMJ. 2020;370:m2632.

    Article  PubMed  Google Scholar 

  20. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155:529–36.

    Article  PubMed  Google Scholar 

  21. Kopp J, Kopp D, Bernhardt E, Manka L, Beck A, Gerullis H, et al. 68Ga-PSMA PET/CT based primary staging and histological correlation after extended pelvic lymph node dissection at radical prostatectomy. World J Urol. 2020;38:3085–90.

    Article  CAS  PubMed  Google Scholar 

  22. Özman O, Veerman H, Contieri R, Droghetti M, Donswijk ML, Hagens MJ, et al. Staging Accuracy and Prognostic Value of Prostate-Specific Membrane Antigen PET/CT Strongly Depends on Lymph Node Tumor Burden. J Clin Med. 2024;13:6534.

  23. Van Bergen TD, Braat A, Hermsen R, Heetman JG, Wever L, Lavalaye J, et al. External validation of nomograms including PSMA PET information for the prediction of lymph node involvement of prostate cancer. Eur J Nucl Med Mol Imaging. 2025;52:3744–56.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Esen B, Seymen H, Armutlu A, Koseoglu E, Aykanat IC, Zoroğlu H, et al. Impact of Pelvic Lymph Node Dissection on Early Oncological Outcomes in Intermediate-Risk Prostate Cancer Patients With Node-Negative PSMA PET. Prostate. 2025;85:777–83.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Surasi DS, Eiber M, Maurer T, Preston MA, Helfand BT, Josephson D, et al. Diagnostic Performance and Safety of Positron Emission Tomography with (18)F-rhPSMA-7.3 in Patients with Newly Diagnosed Unfavourable Intermediate- to Very-high-risk Prostate Cancer: Results from a Phase 3, Prospective, Multicentre Study (LIGHTHOUSE). Eur Urol. 2023;84:361–70.

    Article  CAS  PubMed  Google Scholar 

  26. Ingvar J, Hvittfeldt E, Trägårdh E, Simoulis A, Bjartell A. Assessing the accuracy of [(18)F]PSMA-1007 PET/CT for primary staging of lymph node metastases in intermediate- and high-risk prostate cancer patients. EJNMMI Res. 2022;12:48.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Dekalo S, Kuten J, Campbell J, Mintz I, Bar-Yosef Y, Keizman D, et al. 68)Ga-prostate-specific membrane antigen positron emission tomography/computed tomography for patients with favorable intermediate-risk prostate cancer. Can Urol Assoc J. 2022;16:E381–5.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Frumer M, Milk N, Rinott Mizrahi G, Bistritzky S, Sternberg I, Leibovitch I, et al. A comparison between (68)Ga-labeled prostate-specific membrane antigen-PET/CT and multiparametric MRI for excluding regional metastases prior to radical prostatectomy. Abdom Radiol. 2020;45:4194–201.

    Article  Google Scholar 

  29. Yaxley JW, Raveenthiran S, Nouhaud FX, Samartunga H, Yaxley AJ, Coughlin G, et al. Outcomes of Primary Lymph Node Staging of Intermediate and High Risk Prostate Cancer with (68)Ga-PSMA Positron Emission Tomography/Computerized Tomography Compared to Histological Correlation of Pelvic Lymph Node Pathology. J Urol. 2019;201:815–20.

    Article  PubMed  Google Scholar 

  30. Incesu RB, Preisser F, Pompe RS, Nohe F, Mandel P, Maurer T, et al. Diagnostic Accuracy of Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography for Primary Lymph Node Staging Before Radical Prostatectomy. Eur Urol Focus 2025;11:582–7.

  31. Kim TH, Woo S. How Systematic Review Can Shape Clinical Practice in Radiology. AJR Am J Roentgenol. 2024;222:e2329603.

    Article  PubMed  Google Scholar 

  32. Mazzone E, Cannoletta D, Quarta L, Chen DC, Thomson A, Barletta F, et al. A Comprehensive Systematic Review and Meta-analysis of the Role of Prostate-specific Membrane Antigen Positron Emission Tomography for Prostate Cancer Diagnosis and Primary Staging before Definitive Treatment. Eur Urol. 2025;87:654–71.

    Article  CAS  PubMed  Google Scholar 

  33. Bonaddio J, Carll J, Eapen R, Sathianathen N, Lawrentschuk N. The role of PSMA PET/CT in staging patients with intermediate-risk prostate cancer. BJU Int. 2025;137:49–57.

  34. Cornford P, van den Bergh RCN, Briers E, Van den Broeck T, Brunckhorst O, Darraugh J, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2024;86:148–63.

    Article  PubMed  Google Scholar 

  35. Bonaddio J, Carll J, Eapen R, Sathianathen N, Lawrentschuk N. The role of PSMA PET/CT in staging patients with intermediate-risk prostate cancer. BJU Int. 2026;137:49–57.

    Article  PubMed  Google Scholar 

  36. Hartwieg BF, Maurer T, Kniep C, Mandel P, Wenzel M, Falkenbach F, et al. Use of staging in intermediate-risk prostate cancer: A real-world data analysis. Urol Oncol. 2026;44:71.e71–71.e77.

    Article  Google Scholar 

  37. Cheng L, Zincke H, Blute ML, Bergstralh EJ, Scherer B, Bostwick DG. Risk of prostate carcinoma death in patients with lymph node metastasis. Cancer. 2001;91:66–73.

    Article  CAS  PubMed  Google Scholar 

  38. Daneshmand S, Quek ML, Stein JP, Lieskovsky G, Cai J, Pinski J, et al. Prognosis of patients with lymph node positive prostate cancer following radical prostatectomy: long-term results. J Urol. 2004;172:2252–5.

    Article  PubMed  Google Scholar 

  39. Meijer D, Ettema RH, van Leeuwen PJ, van der Kwast TH, van der Poel HG, Donswijk ML, et al. The prognostic value of lymph node staging with prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) and extended pelvic lymph node dissection in node-positive patients with prostate cancer. BJU Int. 2023;131:330–8.

    Article  CAS  PubMed  Google Scholar 

  40. Pozin J, Bhandari M, Valle L, Nickols NG, Kishan AU, Kamran SC, et al. The Evolving Management of Radiorecurrent Prostate Cancer. Semin Radiat Oncol. 2025;35:450–62.

    Article  PubMed  Google Scholar 

  41. Pollack A, Karrison TG, Balogh AG, Gomella LG, Low DA, Bruner DW, et al. The addition of androgen deprivation therapy and pelvic lymph node treatment to prostate bed salvage radiotherapy (NRG Oncology/RTOG 0534 SPPORT): an international, multicentre, randomised phase 3 trial. Lancet. 2022;399:1886–901.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Fink CA, Wegener D, Sauer LD, Lentz-Hommertgen A, Liermann J, Müller AC, et al. Pelvic Irradiation for Node-Positive Prostate Cancer After Prostatectomy: Long-Term Results of the Prospective PLATIN-4 and PLATIN-5 Trials. Int J Radiat Oncol Biol Phys. 2024;118:1011–7.

    Article  PubMed  Google Scholar 

  43. Clinckaert A, Callens K, Cooreman A, Bijnens A, Moris L, Van Calster C, et al. The Prevalence of Lower Limb and Genital Lymphedema after Prostate Cancer Treatment: A Systematic Review. Cancers 2022;14:5667.

  44. Peilleron N, Seigneurin A, Herault C, Verry C, Bolla M, Rambeaud JJ, et al. External evaluation of the Briganti nomogram to predict lymph node metastases in intermediate-risk prostate cancer patients. World J Urol. 2021;39:1489–97.

    Article  PubMed  Google Scholar 

  45. Kuperus JM, Tobert CM, Semerjian AM, Qi J, Lane BR. Pelvic Lymph Node Dissection at Radical Prostatectomy for Intermediate Risk Prostate Cancer: Assessing Utility and Nodal Metastases Within a Statewide Quality Improvement Consortium. Urology. 2022;165:227–36.

    Article  PubMed  Google Scholar 

  46. Gofrit ON, Orevi M, Ben-Haim S, Meuman T, Duvdevani M, Hidas G, et al. The relevance of nomograms for prediction of pelvic lymph node metastases in the prostate-specific membrane antigen (PSMA)-PET/CT era. Curr Urol. 2025;19:353–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Funding

Jilin Province Health Research Talent Special Project (Grant Number: 2023SCZ46), Department of Finance of Jilin Province.

Author information

Author notes

  1. These authors contributed equally: Qi-Chang Wan, Kai-Yin Min.

Authors and Affiliations

  1. Department of Nuclear Medicine, China-Japan Union Hospital of Jilin University, Changchun, 130033, China

    Qi-Chang Wan, Kai-Yin Min, Lan Wei & Bin Ji

  2. Department of Nuclear Medicine, Affiliated Qingyuan Hospital, Guangzhou Medical University, Qingyuan People’s Hospital, Qingyuan, 511500, China

    Qi-Chang Wan

  3. Department of Nuclear Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China

    Liang-Jun Xie

Authors
  1. Qi-Chang Wan
    View author publications

    Search author on:PubMed Google Scholar

  2. Kai-Yin Min
    View author publications

    Search author on:PubMed Google Scholar

  3. Lan Wei
    View author publications

    Search author on:PubMed Google Scholar

  4. Liang-Jun Xie
    View author publications

    Search author on:PubMed Google Scholar

  5. Bin Ji
    View author publications

    Search author on:PubMed Google Scholar

Contributions

Visualization, Conceptualization, and Writing original draft: Wan Qi-chang; Data curation and Formal analysis: Min Kai-yin; Investigation and Methodology: Wei Lan; Supervision, Validation, Writing – review & editing: Xie Liang-jun. Supervision, Project administration, Validation, and Writing review & editing: Ji Bin.

Corresponding authors

Correspondence to Liang-Jun Xie or Bin Ji.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wan, QC., Min, KY., Wei, L. et al. Can pelvic lymph node dissection be spared in intermediate-risk prostate cancer patients with negative PSMA PET scan? A systematic review and diagnostic meta-analysis. Prostate Cancer Prostatic Dis (2026). https://doi.org/10.1038/s41391-026-01103-w

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Version of record:

  • DOI: https://doi.org/10.1038/s41391-026-01103-w

Search

Advanced search

Quick links