在前列腺特异性膜抗原（PSMA）正电子发射断层扫描/计算机断层扫描（PET/CT）显示临床淋巴结病灶的前列腺癌（PCa）患者中，包括激进前列腺切除术（RP）在内的局部治疗的作用很少被探讨。目前只有有限的数据可用于识别能够受益于RP的患者；相反，那些可能获益的已经有系统性疾病。我们旨在通过整合临床、磁共振成像（MRI）和PSMA PET/CT参数，评估行手术治疗的临床淋巴结病灶阳性的PCa患者中前列腺特异性抗原（PSA）持续存在的预测因素。我们在九个转诊中心中找到了在2017年至2022年之间接受RP和扩大淋巴结切除手术治疗的519名患者，并进行了术前PSMA PET筛查。其中，我们选择了88例在术前PSMA PET中显示淋巴结摄取的患者（miTxN1M0）。结果显示，32例（36%）RP后PSA持续存在。多变量逻辑回归模型检测了PSA持续存在的预测因子。协变量包括活检国际泌尿学病理学学会（ISUP）级别、MRI下的临床分期以及PET/CT扫描中的阳性病灶数目。回归树分析根据术前特征将患者分层为风险组。总体而言，淋巴结浸润（LNI）在63例患者中被检测到（72%），并且在RP后发现有PSA持续存在。在多变量分析中，术前PSMA PET发现超过两个淋巴结阳性病灶、MRI下的精囊浸润（SVI）以及活检ISUP级别>3是PSA持续存在的独立预测因子（所有p <0.05）。回归树分析显示，根据活检ISUP级别、PET/CT中阳性病灶数目以及MRI下的临床分期，将患者分层为四个风险组。该模型在内部验证中展现出良好的判别能力（曲线下面积为78%）。三分之一的miN1M0患者RP后显示有PSA持续存在。ISUP级别为2-3的患者，以及MRI下有局限性疾病并且PET中仅有一个或两个阳性淋巴结病灶的患者是在多模态治疗背景下RP可能获得最佳肿瘤学结果的患者。相反，具有较高ISUP级别、外包膜扩展、SVI或PET发现两个以上病灶的患者应被视为可能已受到系统性疾病的影响。我们的新颖和简明的风险分类结合了目前可用的术前风险工具，并应协助医生在行前列腺特异性膜抗原正电子发射断层扫描的阳性淋巴结摄取的前列腺癌患者的手术咨询中使用。版权©2023欧洲泌尿学协会。Elsevier B.V.保留所有权利。

The role of local therapies including radical prostatectomy (RP) in prostate cancer (PCa) patients with clinical lymphadenopathies on prostate-specific membrane antigen (PSMA) positron emission tomography/computerized tomography (PET/CT) has scarcely been explored. Limited data are available to identify men who would benefit from RP; on the contrary, those more likely to benefit already have systemic disease.We aimed to assess the predictors of prostate-specific antigen (PSA) persistence in surgically managed PCa patients with lymphadenopathies on a PSMA PET/CT scan by integrating clinical, magnetic resonance imaging (MRI), and PSMA PET/CT parameters.We identified 519 patients treated with RP and extended lymph node dissection, and who received preoperative PSMA PET between 2017 and 2022 in nine referral centers. Among them, we selected 88 patients with nodal uptake at preoperative PSMA PET (miTxN1M0).The outcome was PSA persistence, defined as a PSA value of ≥0.1 ng/ml at the first measurement after surgery. Multivariable logistic regression models tested the predictors of PSA persistence. Covariates consisted of biopsy International Society of Urological Pathology (ISUP) grade group, clinical stage at MRI, and number of positive spots at a PET/CT scan. A regression tree analysis stratified patients into risk groups based on preoperative characteristics.Overall, lymph node invasion (LNI) was detected in 63 patients (72%) and 32 (36%) experienced PSA persistence after RP. At multivariable analyses, having more than two lymph nodal positive findings at PSMA PET, seminal vesicle invasion (SVI) at MRI, and ISUP grade group >3 at biopsy were independent predictors of PSA persistence (all p < 0.05). At the regression tree analysis, patients were stratified in four risk groups according to biopsy ISUP grade, number of positive findings at PET/CT, and clinical stage at MRI. The model depicted good discrimination at internal validation (area under the curve 78%).One out of three miN1M0 patients showed PSA persistence after surgery. Patients with ISUP grade 2-3, as well as patients with organ-confined disease at MRI and a single or two positive nodal findings at PET are those in whom RP may achieve the best oncological outcomes in the context of a multimodal approach. Conversely, patients with a high ISUP grade and extracapsular extension or SVI or more than two spots at PSMA PET should be considered as potentially affected by systemic disease upfront.Our novel and straightforward risk classification integrates currently available preoperative risk tools and should, therefore, assist physician in preoperative counseling of men candidates for radical treatment for prostate cancer with positive lymph node uptake at prostate-specific membrane antigen positron emission tomography.Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.