Decision on removing lymph nodes during Ralp procedure

They cannot remove all the lymph nodes that the cancer potentially spread to. They remove a sample to check if cancer is present. If it is, you will get salvage RT.

My five cents: With a cancer that is already T3, I would seriously consider RT instead of surgery. Have you gotten second opinions from radiologists?

Hi,
My surgeon said the lymph nodes looked healthy so he left mine in. Your surgeon might decide during surgery on whether to leave or remove them. Leave that decision up to your surgeon.
Dave 3+4

Here are some information so you can think about what you want to do with this decision

Lymph node removal

"Lymph nodes aren't just passive waiting rooms for immune cells, they actively train and educate T cells, and send them off to do their job," said Professor Axel Kallies, PhD, Laboratory Head at the Doherty Institute and the corresponding author on both studies. "Our research suggests that removing lymph nodes during cancer surgery, a common practice to prevent tumor spread, may inadvertently reduce the effectiveness of treatments, such as checkpoint blockade and CAR T cell therapies. Preserving lymph nodes could strengthen immune responses and increase the effectiveness of immunotherapy."

But what are lymph nodes, and what do they do?
Lymph nodes are small, bean-shaped organs scattered throughout the body that act as checkpoints of the immune system. They filter lymph fluid, which drains from tissues, trapping and destroying germs, cancer cells, and other harmful material. Inside, lymph nodes are packed with immune cells like T cells, B cells, and dendritic cells that communicate, train, and multiply in response to threats.

Summary of the surgeons I consulted with:
Dr. John Ward, MD Anderson - does not remove lymph nodes. He said risks outweigh reward.
Dr. Ronney Abaza - generally removes lymph nodes. You can watch him perform RARP on YouTube if you dare.
Dr. Christopher Weight, Cleveland Clinic - removed 15 lymph nodes during my RARP.

Age 50 at time of surgery in June 2025; 3+4, T1C based on pre-op biopsy, negative PSMA, Decipher 0.56, but T3B based on post-op pathology. So far my PSA has been undetectable and I did not have any known lymphocele or other issues.

They took some from each side of me during surgery. I thought it was SOP to check for spread. No problems that I am aware of 4 years later.

My husband had a Gleason 4+5 after the biopsy. His surgeon removed 15 lymph nodes, more at the side of the tumor. He got a large lymphocele after the surgery, especially on this side. It took many, many weeks to dissolve, but thank god it finally did. We were worried that it would develop into a permanent lymphedema. That may happen from a lymphocele when lymph nodes have been removed. It hasn't happened, at least up to now, but if my husband is really unlucky, it may still do so.

The surgeon doesn't remove a specific number of lymph nodes, he does not even remove the lymph nodes per se. They remove some tissue from which the pathologists extract a number of lymph nodes later. If I understood it correctly, they do not know before how many there will be in. They find more (as in my husband's case) or less. It seems also that the total number of lymph nodes one has varies significantly.

In my layman's understanding, the problem is not only that a few lymph nodes are missing, but also or even more that damage that is done to the lymph vessels and the surrounding tissue by cutting them out. Most people have no side effects or little swelling only. It clearlay depends also on the extent of the dissection. However, the side effects of an ectomy are much more grave than radiating lymph nodes.

They take them mainly out for diagnostic purposes as we have understood. With the availability of PSMA-PET Scans and ultra-sensitive PSA testing, there may be less need for extensive and distant lymphadectomy. In former times they must have taken out many more nodes than today, we were told! There may be cases in which the cancer had spread to an extracted lymph node and not yet further. Then the lymphadectomy has cleary an advantage. But as others have written, there are pros and cons. If the spread is rather unlikely, I don't know... Unfortunately, I cannot give you any good advice. If I was in the decision situation again, I would ask our doctors whether removing the prostate and radiating well targeted a few lymph nodes would make any sense. (Probably not) All the best!

Yes, I have talked to RT and done a lot of research on both RT & Surgery. My decision for surgery was based on a few criteria: ADT drugs, longer-term effects of radiation, ability to perform salvage surgery after radiation, and family history/experinece. I am working with an excellent cancer center in Colorado and a highly experienced surgeon. It was a difficult decision between the two. Sincerely, appreciate your comments. Thank you

Thank you, Dave. Appreciate your advice.

Thank you very much, Jeff. I appreciate the information, as it will certainly be helpful as I continue my research.

Glad to hear of your continued success! Appreciate the summary of the doctors you consulted with. Thank you for your response.