Recent advances in functional imaging, such as prostate-specific membrane antigen positron emission tomography (PSMA PET/CT), provide earlier detection of nodal recurrent prostate cancer. Current studies on metastasis-directed therapy in patients with node-only recurrence suggest a positive influence on the prognosis in selected patients. Nevertheless, most studies are retrospective and, due to a lack of high-level evidence, salvage lymph node dissection (SLND) is not recommended by current guidelines.The aim of this work is to provide a critical summary of the current data on SLND in patients with nodal recurrent prostate cancer with a focus on imaging procedures, extent of SLND and oncological outcome.European guidelines recommend the use of choline or PSMA PET/CT imaging if prostate cancer recurrence is suspected. PSMA PET/CT is superior to choline PET/CT in sensitivity and specificity and should be the preferred approach. Nevertheless, if SLND is performed, common practice is bilateral SLND - even if only unilateral lymph node involvement is detected by PSMA PET/CT. However, unilateral SLND can also be considered. A randomised prospective trial (ProSTone) is being initiated for clarification.PSMA radioguided surgery seems to be a new promising surgical approach. It facilitates the intraoperative detection of lymph node metastases. However, long-term data are still awaited.All in all, SLND achieves a respectable biochemical response rate in carefully selected patients. Nevertheless, prospective studies are necessary in the future in order to define the clinical usefulness more precisely.
