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The aim of this study was to determine the role of PSMA-PET/CT imaging in patients who experience biochemical persistence (BCP) after robot-assisted laparoscopic radical prostatectomy (RARP). 150 patients with BCP after RARP who underwent radiolabeled PSMA-PET/CT imaging were evaluated. A multivariable logistic regression analysis was performed to identify predictors for the detection of metastases outside the prostatic fossa (≥ miN1) on PSMA-PET/CT. Results: In total, 89/150 patients (59%) had ≥ miN1 on PSMA-PET/CT at BCP. On multivariable analysis, higher PSA-values after RARP (p = 0.004) and positive pathological lymph node status (p = 0.006) were independent predictors for ≥ miN1. In presence of BCP, a high proportion of patients had ≥ miN1 disease, indicated by PSMA-PET/CT. Higher PSA-levels after RARP and positive pathological lymph node status were significantly associated with metastases outside the prostatic fossa. In conclusion, in patients with BCP, PSMA-PET/CT imaging is warranted to guide (salvage) treatment strategies.

177Lu-PSMA is a new, promising treatment option in patients with metastatic castration-resistent prostate carcinoma (mCRPC). The radioactive-labeled medication is given intravenously in 1–6 cycles, in which the β‑radiation causes damage to the cellular DNA and eventually cell death of prostate cancer cells that express PSMA. In mostly retrospective studies, a decrease is seen in the serum-PSA level of ≥ 50% in 40–60% of patients that have been previously extensively treated. A survival benefit is observed, but mostly within non-randomized studies. The toxicity of treatment is relatively mild with grade I–II CTCAE xerostomia in 30–50% of patients and a passing grade III–IV CTCAE hematologic toxicity (thrombocytopenia, leukopenia) in 0–15%. The medication is under study in multiple prospective studies in patients with mCRPC and in one randomized clinical trial. The use of 177Lu-PSMA in patients with earlier phases of disease is explored. Until proven of benefit in RCTs, 177Lu-PSMA therapy remains experimental.