Now that we are detecting prostate cancer much earlier due to PSA testing, it is rare to find lymph node metastases. Predictors of lymph node involvement are high PSA level (greater than 20), Gleason grade higher than 7, many biopsy cores containing cancer, and a very abnormal feeling prostate on digital rectal examination. Lymph node biopsy is not mandatory in the absence of any of these features. My policy is to remove a small tissue packet containing 1-3 of the so-called “first echelon” lymph nodes near the prostate. Lymph node involvement is an unfavorable prognostic sign. However, two small case-control studies from Johns Hopkins and the Mayo Clinic suggest that the outcome is better if the prostate is removed in patients with minimal lymph node involvement. About 95% of my patients elect to proceed with removal of the prostate even if the lymph nodes are involved.