A novel nomogram incorporating lymphovascular invasion to predict lymph node invasion in high-risk prostate cancer.

Accurate preoperative prediction of lymph node invasion (LNI) is essential for selecting candidates for extended pelvic lymph node dissection (ePLND) in high-risk prostate cancer. Although ePLND provides the most reliable nodal staging, it is associated with increased operative time and postoperative complications. Existing predictive models have limited validation in Asian populations and rarely incorporate lymphovascular invasion (LVI). We retrospectively analyzed 325 patients with high-risk prostate cancer who underwent radical prostatectomy with ePLND between 2019 and 2023. Multivariable logistic regression was used to identify independent predictors of LNI and to develop a novel nomogram integrating LVI with established clinical parameters. Model performance was evaluated using receiver operating characteristic analysis, calibration curves, clinical impact curves, and decision curve analysis, and compared with the Briganti 2012, Briganti 2017, and MSKCC models. LVI, seminal vesicle invasion, biopsy Gleason grade group, clinical stage, and preoperative prostate-specific antigen were independent predictors of LNI. The proposed model demonstrated discrimination (AUC = 0.89; 95% CI 0.85–0.93) and good calibration. At a 7% risk threshold, 31.3% of ePLND procedures could be avoided while missing only 1.7% of LNI cases. Incorporation of LVI significantly improves preoperative prediction of nodal metastasis and may support more individualized surgical decision-making.