The pelvic lymph nodes are a common site of prostate cancer dissemination. Unlike distant organ metastases such as bone, lung, and liver, prostate cancer with pelvic lymph node metastases is still classified as a regional lesion, between a local and a distantly disseminated lesion. At the same time, the management of prostate cancer with pelvic lymph node metastasis is subject to academic debate on whether it should be treated aggressively locally or with palliative endocrine therapy. In the 2016 ASCO-GU meeting, we discussed this challenge in depth, summarized previous literature data, and proposed new tools and strategies to guide clinical practice. 1. Should local therapy be added for prostate cancer with pelvic lymph node metastasis? Previous randomized controlled studies have confirmed that locally advanced prostate cancer should be treated with local therapy in addition to endocrine therapy. This gap was filled by the 2015 data from the National Cancer Database, which divided the cases in the database into two groups: endocrine therapy alone and endocrine therapy plus local radiotherapy. vs. 53.2%) showed a significant improvement. Also, the authors performed a subgroup analysis based on age, tumor stage, Gleason score and PSA to investigate in which group of patients the addition of local therapy was more beneficial. The results showed that the addition of local therapy had a more significant improvement in survival for patients in the age <65 years, T1 to T 2 stage, Gleason score 8-10 or PSA ≥20 ng/ml groups. For example, patients in the Gleason score 8-10 group had a 5-year survival rate of only 6% with endocrine therapy alone, which increased to 37% with the addition of topical therapy, a difference of 31% (p=0.001). Another population-based database similarly confirmed that patients with prostate cancer with pelvic lymph node metastases had better survival rates after radical prostate cancer treatment, with a 50% lower risk of death than with endocrine therapy alone. Although data from randomized controlled clinical studies are still lacking, preliminary retrospective data suggest that local treatment is the preferred option for prostate cancer with pelvic lymph node metastases. How to accurately detect pelvic lymph node micrometastases? Local treatment can improve the prognosis of prostate cancer with pelvic lymph node metastases, but not all prostate cancer patients have lymph node metastases, so the development of a local treatment plan depends on accurate pelvic lymph node assessment - confirming the presence of cancer metastases in the lymph nodes prior to treatment. The assessment of pelvic lymph nodes is currently performed at three levels: conventional CT tomography or MRI, functional tumor imaging with choline PET/CT, and prostate cancer-specific imaging with PSMA PET/CT. First, in terms of sensitivity, i.e., the ability to accurately identify lymph node metastases: conventional CT or MRI has a sensitivity of only 42%, and the addition of diffusion imaging only increases the sensitivity to 57%; choline PET/CT has a sensitivity of only 10%. The sensitivity of choline PET/CT is slightly improved, reaching 60%, while the latest PSMA PET/CT can increase it to 66%. This means that still 1/3 of lymph node metastases are missed. Secondly, the specificity of these exams, which has improved from 82% with CT/MRI to 99% with PSMA PET/CT, means that the probability of misdiagnosing lymph node metastases is significantly reduced. Therefore, as far as examination means are concerned, the diagnostic efficacy of PSMA PET/CT, although significantly improved compared to CT/MRI, still needs to be improved in terms of sensitivity and cannot replace the staging role of surgery. The scope and indications of pelvic lymph node dissection The pelvic lymph node dissection surgery can confirm the accurate lymph node staging status through pathological analysis to guide the follow-up treatment and follow-up. In the past, pelvic lymph node dissection surgery for prostate cancer was limited to the closed-hole area, and recent studies suggest that the scope of conventional dissection is too limited. European scholars have demonstrated that 75% of lymph node metastases are located in the pelvic lymphatic drainage area below the position of the ureter across the iliac vessels by lymphography. Further analysis of data from 1031 extended lymph node dissection procedures confirmed that 65.8% of metastatic lymph nodes were located in the foraminal region, however, 35.2% of metastatic lymph nodes were in the internal iliac region and 45.6% were in the external iliac region. When lymph node dissection includes the external, closed-hole, and internal iliac regions, the likelihood of missing metastatic lymph nodes is often less than 10%, so the scope of lymph node dissection for prostate cancer should be gradually revised to include the external, closed-hole, and internal iliac regions. The risk of lymph node metastasis is closely related to the malignancy of prostate cancer itself. Data from 5274 cases of extended pelvic lymph node dissection for prostate cancer in Italy showed that the risk of lymph node metastasis in low-risk prostate cancer (cT1c and PSA <10 7="" 20="" gleason="" psa="" >20 ng/ml) was 25-44%. Based on the risk-benefit ratio of surgery, the three major guidelines of EAU, AUA and NCCN recommend pelvic lymph node dissection in patients with intermediate to high-risk prostate cancer. Risk groupings based on T-stage, Gleason score and PSA are crude and cannot be assessed quantitatively, so many authors have developed integrated prediction models to provide more specific risk values that can help better individualize prediction. Expanded pelvic lymph node dissection can be performed by both open and lumpectomy, and comparative data show that the total number of lymph nodes and the rate of positive lymph nodes are essentially the same in both groups. The key factor in the lymph node dissection procedure remains the experience of the surgeon, with more than 100 surgical operations to ensure consistent surgical quality. 4. Adjuvant treatment options after lymph node dissection surgery Lymph node metastatic prostate cancer is an intermediate stage between limited and distantly disseminated lesions. In addition to local surgical treatment, follow-up adjuvant therapy is of great value. As early as 2006, Professor Messing conducted a randomized controlled clinical trial to compare the advantages and disadvantages of early endocrine therapy versus follow-up for lymph node metastatic prostate cancer. The results showed that follow-up increased the risk of death by 84%, significantly worse than early endocrine therapy (p=0.04). In addition to endocrine therapy, radiotherapy is also an option for postoperative lymph node metastatic prostate cancer, and Prof. Briganti compared the long-term outcomes of endocrine therapy alone and endocrine therapy combined with radiotherapy in a retrospective study, showing that the difference in survival rates between the two groups was 8% at 5 years and expanded to 19% at 10 years, with an overall survival rate of 74% at 10 years in the group treated with endocrine therapy combined with radiotherapy. 74%. Further multifactorial analysis showed that adjuvant radiotherapy benefited two groups: (i) one to two metastatic lymph nodes, Gleason score 7-10, pT3b/4 or positive cut margins; and (ii) three to four metastatic lymph nodes. Since adjuvant radiotherapy did not significantly improve survival in patients with mild local lesions (Gleason score ≤6, T stage ≤T3a) or excessive metastases (positive lymph nodes >4), its suitable population should be cases with a high possibility of local residual after surgery.