Robotic salvage lymph node dissection (PSMA-guided)
Robotic surgery to remove lymph nodes where prostate cancer has come back, found on a PSMA PET scan, usually years after prostatectomy or radiation. It is a selective treatment for a small group of men and is often combined with radiation or hormone therapy.
Also called Salvage lymph node dissection, sLND, Salvage pelvic lymph node dissection, PSMA-guided lymph node surgery, PSMA-guided surgery, PSMA radioguided surgery, Robotic lymph node removal for prostate cancer, Metastasis-directed surgery
- Where
- Hospital operating room
- Anesthesia
- General anesthesia (fully asleep)
- Time in the room
- About 2 to 4 hours
- Hospital stay
- Usually one night; sometimes same day or two nights
- Going home with
- Sometimes a small drain for a day or two; a bladder catheter only during or just after surgery
- Back to normal
- About 2 to 4 weeks
- Back to work
- Desk work in about 1 to 2 weeks; heavy physical work in about 4 to 6 weeks
Overview
When the PSA blood test starts to rise after prostatectomy or radiation, it means some prostate cancer cells are still alive somewhere. A PSMA PET scan can now find where they are much earlier than older scans. PSMA (prostate-specific membrane antigen) is a protein on the surface of most prostate cancer cells. The tracer used in the scan sticks to it, and those spots light up. Sometimes the scan shows cancer in only one or a few lymph nodes, the small bean-shaped filters along the blood vessels, and nowhere else.
A salvage lymph node dissection removes those lymph nodes, along with the other nodes and fatty tissue around them. Your surgeon takes more than the bright spot, because PSMA PET can miss very small deposits nearby. Most often the nodes are in the pelvis, along the iliac vessels. Sometimes they are higher up, at the back of the belly beside the aorta and vena cava, the body's largest artery and vein. The operation is usually done with the robot through small keyhole cuts.
Be clear about what it can and cannot do. After surgery, the PSA falls in many men and becomes very low in some. In most men it later rises again, because cancer cells were also elsewhere, too small to see. A lasting cure is uncommon. A realistic goal for many men is more time before hormone therapy is needed, with its side effects. No randomized trial has shown that this surgery helps men live longer, and major guidelines treat it as an option for carefully selected men in experienced centers, ideally within studies or registries.
Surgery is not the only way to treat a few spots. Focused radiation (stereotactic body radiation therapy, or SBRT) is often used for the same purpose without an operation. In the STOMP trial, treating the spots with either surgery or focused radiation delayed the need for hormone therapy compared with watching. Your team may also recommend combining surgery with radiation to the node areas or a course of hormone therapy.
The parts of your body involved
Lymph nodes sit along the blood vessels like beads on a string. Prostate cancer that spreads usually reaches the pelvic nodes first: those along the external and internal iliac vessels, in the obturator space near the obturator nerve, and over the sacrum. From there it can move up to the common iliac nodes and then to nodes beside the aorta and vena cava, at the back of the belly. Nearby are the ureters, which carry urine from the kidneys, and, higher up, nerves that control ejaculation. The drawings show the prostate in place. If it was removed earlier, the bladder sits directly on the urethra.
- Pelvic lymph nodes
Nodes along the iliac vessels and in the obturator space. The most common place for prostate cancer to come back outside the prostate area.
- Iliac artery and vein
The large blood vessels that carry blood to and from each leg. The nodes are peeled off their surface.
- Obturator nerve
A nerve running through the pelvis that moves the thigh inward. It is protected throughout.
- Ureter
The tube carrying urine from each kidney to the bladder. It crosses the iliac vessels, right in the work area, and is moved gently aside.
- Retroperitoneal nodes
Nodes beside the aorta and vena cava at the back of the belly. Cancer here is usually treated with focused radiation, and less often with surgery.
Why it’s done
This surgery is considered when a PSMA PET scan shows prostate cancer has come back only in a small number of lymph nodes, the man is healthy, and he and his team want to treat the visible cancer directly rather than start lifelong hormone therapy right away.
- To remove the cancer the scan found
Taking out the nodes that lit up, with the tissue around them, removes the visible cancer.
- To delay hormone therapy
Hormone therapy controls prostate cancer for years but often causes hot flashes, tiredness, weight gain, bone thinning and loss of sex drive. Treating the spots directly may postpone it.
- To confirm what the scan showed
The pathologist checks every node, confirming whether the bright spots were cancer and finding small deposits the scan missed.
- When the area was already radiated
If the pelvis already had full-dose radiation, giving more there is limited. Surgery can reach nodes in an area that cannot safely receive much more radiation.
- As part of a combined plan or a study
Some teams combine node surgery with radiation to the node areas or with hormone therapy, and many men take part in studies testing the best combination.
Other options
- Focused radiation to the spots (SBRT)
A few high-dose radiation sessions aimed precisely at each node, with no incision. It is the most common way to treat a few spots and has similar goals to surgery.
- Radiation to the pelvis with hormone therapy
After prostatectomy, radiation to the area where the prostate was and to the pelvic nodes, with several months of hormone therapy, is a standard treatment for a rising PSA.
- Hormone therapy
Medicines that lower or block testosterone, sometimes with newer hormone pills. They control the cancer for years but do not cure it.
- Watching closely
When the PSA rises slowly, some men choose regular PSA tests and repeat scans, treating only when needed.
- A clinical trial
Many trials are testing surgery, focused radiation and drug combinations for a few spots of returning cancer. Ask whether one fits you.
Getting ready
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Weeks before
The week before
The day before
The morning of surgery
In the operating room, step by step
Press play or pick a step. Each drawing shows what your surgeon is doing at that moment. Your team may do some steps differently.
1. Going to sleep and positioning
The anesthesiologist puts you fully to sleep and places a breathing tube. A catheter is placed in the bladder for the operation. For pelvic nodes, the table is tilted head-down so the bowel slides out of the pelvis.
More detail
For nodes higher up, beside the aorta and vena cava, you lie flat or slightly turned, and the bowel is moved aside instead.
The surgeon sits at a console a few steps from you and moves every instrument with hand controls and foot pedals. The robot cannot move on its own or make decisions.
A camera on one arm gives the surgeon a bright, three-dimensional picture magnified about ten times, which helps them see small nerves and vessels.
The instruments are about the width of a pencil and bend like a wrist inside your body, so the surgeon can stitch and dissect through small openings.
A bedside assistant and a scrub nurse stay at the table, and the anesthesia team watches your breathing and blood pressure throughout. Most U.S. hospitals use the da Vinci system made by Intuitive.
After the operation
Right afterward
- Waking up
You are watched in the recovery room for 1 to 2 hours. Soreness at the cuts and shoulder-tip gas pain are common.
- Walking and eating
You walk the same evening and usually drink and eat light food the same day or next morning.
- Pain control
Scheduled acetaminophen, sometimes with an anti-inflammatory, and few opioid pills.
- Catheter and drain
The bladder catheter usually comes out before you leave. If you have a drain, it comes out when the fluid slows, often before you go home.
- Blood clot prevention
You may get blood thinner shots in the hospital, and some men go home with daily shots for a few weeks.
- Going home
Most men go home after one night.
At home
- Pain
Soreness at the cuts and in the lower belly for 1 to 2 weeks. Acetaminophen on schedule usually controls it.
- Wounds and showering
You can usually shower after 24 to 48 hours. Skin glue peels off in 1 to 2 weeks. Avoid baths and swimming for about 2 weeks.
- Leg or groin swelling
Some men notice mild swelling of a leg, the groin or the scrotum as lymph fluid finds new paths. Raising the legs and walking help. Tell your team if it grows.
- Diet
Eat normally unless told otherwise. After nodes are removed from the back of the belly, some surgeons ask for low-fat food for a short time.
- Bowels
Take a stool softener while on any opioid pills and avoid straining.
- Activity and lifting
Walk several times a day. Avoid lifting more than about 10 to 15 pounds and hard exercise for about 4 weeks.
- Driving
Do not drive while taking opioid pain pills. Most men drive again within 1 to 2 weeks.
- Work
Desk work is often possible in 1 to 2 weeks; heavy work in about 4 to 6 weeks.
- Sex
You can resume sexual activity when comfortable, usually after about 2 weeks.
Recovery timeline
- Day 0Surgery day
Surgery takes about 2 to 4 hours. You walk that evening.
- Day 1Home
Most men go home the next day with no tubes or with a small drain.
- Weeks 1 to 2Pathology results
The report lists how many nodes were removed and how many contained cancer.
- Weeks 2 to 4Back to routine
Most men are back to normal activities.
- Weeks 4 to 8First PSA test
The first PSA shows how much the level has fallen. Your team uses it to decide whether more treatment is needed now.
- 2 to 3 monthsNext steps
Depending on the PSA and pathology, your team may recommend radiation to the node areas, hormone therapy, or simply watching.
- Long termRegular PSA checks
PSA tests every few months, with a repeat PSMA PET if the PSA rises again.
What it feels like
Most men find the operation itself easier to recover from than their first prostate treatment. The harder part is the uncertainty: waiting for the PSA, and knowing this treatment often buys time rather than a cure.
Seeing the scan
Seeing spots light up on a PSMA PET scan after years of feeling cured can be frightening. Some men also feel hope that the cancer can be found and treated.
What helpsAsk your team to show you the scan and explain what each spot means. A few lymph node spots are very different from widespread cancer.
Choosing between surgery and radiation
With no clear winner in trials, many men feel unsure which path to choose.
What helpsMeet both a surgeon and a radiation oncologist. Ask each about side effects, how often PSA becomes undetectable, and what happens if it rises again.
Waking up
Soreness at the cuts, some bloating and shoulder-tip pain. Most men are up and walking within hours.
What helpsWalking and regular acetaminophen help the gas pain.
The first weeks
Tiredness and mild soreness. Some men notice swelling in a leg or the groin.
What helpsWalk daily, raise your legs when resting, and tell your team about swelling that grows.
The pathology call
Learning how many nodes had cancer can bring relief or new worry.
What helpsAsk what the number of positive nodes means for your plan and whether more treatment is advised now.
The first PSA
The PSA after surgery carries a lot of hope, and a result that falls but does not reach zero can be disappointing.
What helpsAsk ahead of time what result your team expects and what each possible result would mean.
If the PSA rises again
Many men feel discouraged, even when they were told this was likely.
What helpsRemember that time without hormone therapy is a real benefit. There are many effective next treatments, and your team will plan them with you.
How well it works
Success is measured by how far the PSA falls, how long it stays low, and how long you can go before needing hormone therapy.
- The pathology report
It lists how many nodes were removed and how many contained cancer. Finding cancer in more nodes than the scan showed is common.
- PSA response
In published series, the PSA falls in many men after surgery and becomes very low in roughly a third to a half. A lower PSA before surgery and fewer cancer nodes predict a better response.
- Time without hormone therapy
Many men go months to years before needing hormone therapy. In the STOMP trial, treating a few spots with surgery or focused radiation delayed hormone therapy compared with watching.
- Long-term outlook
In most men, the PSA rises again over the following years. Lasting cure is uncommon, and no trial has yet shown longer survival from this surgery.
- Follow-up imaging
If the PSA rises again, a repeat PSMA PET can show where, guiding the next treatment.
Risks
Every operation has risks. These are the ones people ask about most, with honest odds where good numbers exist. Your surgeon’s own results matter more than averages.
Common
This is a feature of the disease, not a complication. Because tiny deposits can be anywhere, most men eventually need further treatment.
Soreness at the cuts and tiredness for 1 to 2 weeks.
Shoulder-tip pain and bloating for 1 to 3 days.
Fluid often collects where nodes were removed. Most collections are small and harmless and go away on their own.
Less common
A large fluid pocket can cause pain, leg swelling or infection and may need draining with a thin tube placed through the skin.
Swelling from lymph fluid that drains more slowly. It is more likely after earlier node removal or radiation.
Stretching or injury to this nerve can weaken the inner thigh muscles. It usually improves with physical therapy.
The ureter can be injured in scar tissue. It is usually repaired at once, sometimes with a stent left in for a few weeks.
Uncommon. Walking, leg sleeves and blood thinner shots lower the clot risk.
After nodes are removed from beside the aorta, men who still ejaculate may lose ejaculation.
Rare
The nodes lie on large vessels. Serious bleeding is rare and is controlled during surgery, sometimes needing a transfusion or an open incision.
After removal of higher nodes, a lymph channel can leak fat-rich fluid. It usually settles with a low-fat diet.
Rare, and usually repaired at once.
Rarely needed, for bleeding or dense scar.
Call your care team or go to the emergency room if
- Fever of 101°F (38.3°C) or higher, or shaking chills.
- Swelling, pain or warmth in one calf or thigh. Call 911 for sudden shortness of breath or chest pain.
- New or growing swelling in the lower belly, groin or leg, or pelvic pressure with trouble passing urine.
- A swollen, tight belly, repeated vomiting, or no gas or bowel movement for 3 days.
- Weakness moving your thigh inward, or numbness of the inner thigh, that is new or worsening.
- Redness spreading from a cut, pus, or a wound that opens.
- Drain fluid that suddenly increases, turns milky, or looks like blood.
Questions to ask your surgeon
- What does my PSMA PET show, and how many spots are there?
- Is surgery or focused radiation the better choice for me, and why?
- Would you combine surgery with radiation or hormone therapy?
- How many salvage lymph node operations have you done?
- Which areas will you clear, and on one side or both?
- Will you use a tracer probe or dye to help find the nodes?
- What is the chance my PSA becomes very low, and for how long?
- If my PSA rises again, what would come next?
- Is there a clinical trial I could join?
- What is my risk of leg swelling or a lymph fluid collection?
Words you may hear
- Pneumoperitoneum
- The gas-filled belly that makes keyhole surgery possible. Carbon dioxide is pumped in through a thin needle or the first port until the belly wall lifts like a tent (usually at a pressure of 12 to 15 mmHg), giving the camera and instruments room to work. The gas is let out at the end, and the little that remains is absorbed and breathed out over a day or two; it can cause shoulder-tip ache in the meantime.
- PSMA
- Prostate-specific membrane antigen, a protein on the surface of most prostate cancer cells.
- PSMA PET scan
- A scan using a tracer that sticks to PSMA, making small areas of prostate cancer light up.
- Lymph node
- A small bean-shaped filter along the blood vessels, where cancer often spreads first.
- Oligorecurrent
- Cancer that has come back in only a few spots.
- Biochemical recurrence
- A rising PSA showing that cancer has come back, often before it can be felt or seen.
- Template
- A defined area of lymph nodes that the surgeon clears completely.
- Radioguided surgery
- Using a small dose of radioactive tracer and a handheld probe to find cancer nodes during surgery.
- SBRT
- Stereotactic body radiation therapy: a few high-dose radiation treatments aimed precisely at small targets.
- Metastasis-directed therapy
- Treating each visible spot of spread cancer directly, with surgery or focused radiation.
- Hormone therapy (ADT)
- Medicines that lower or block testosterone to slow prostate cancer.
- Lymphocele
- A pocket of lymph fluid that collects where nodes were removed.
- Lymphedema
- Swelling from lymph fluid that drains slowly, often in a leg.
- Retroperitoneum
- The space at the back of the belly, behind the bowel, where the aorta, vena cava and kidneys lie.
Common questions
If only one node lit up, why remove more?
PSMA PET is very good but can miss deposits smaller than a few millimeters. Nearby nodes often contain cancer that did not show, so clearing the area gives a better chance of removing it all.
Can this cure me?
For a small number of men the PSA stays undetectable for years. For most, it buys time before hormone therapy is needed. It is best seen as one step in a longer plan.
Is surgery better than radiation for the spots?
They have not been directly compared in a large trial. Focused radiation needs no incision and is used more often; surgery gives tissue to examine and can clear a wider area. Many men talk with both specialists.
Will I still need hormone therapy?
Many men eventually do. The goal is often to delay it, sometimes for years. Some teams recommend a short course together with surgery or radiation.
Can I have this if I had lymph nodes removed during my prostatectomy?
Yes, though scar tissue makes it harder. Your surgeon will review your earlier operation report.
How soon will I know if it worked?
The first PSA, usually about 4 to 8 weeks after surgery, gives the first answer. The trend over the next months tells more.
Sources this page draws on
- European Association of Urology, EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer (section on persistent PSA and biochemical recurrence)
- American Urological Association, American Society for Radiation Oncology and Society of Urologic Oncology, Advanced Prostate Cancer: AUA/ASTRO/SUO Guideline (2020)
- Journal of Clinical Oncology, Surveillance or metastasis-directed therapy for oligometastatic prostate cancer recurrence: a prospective, randomized, multicenter phase II trial (STOMP; Ost and colleagues) (2018)
- JAMA Oncology, Outcomes of observation vs stereotactic ablative radiation for oligometastatic prostate cancer: the ORIOLE phase 2 randomized clinical trial (2020)
- American Cancer Society, Treating Prostate Cancer That Doesn't Go Away or Comes Back After Treatment
Written November 2026. This page explains what usually happens. It is not medical advice and does not replace a conversation with your own surgeon, whose plan for you comes first.