Lymph node invasion in prostate cancer is a significant prognostic factor indicating worse prognosis. While it affects significantly both survival rates and recurrence, proper management remains a heated issue. Thorough evaluation of risk factors associated with nodal involvement, such as lymph node density or extracapsular extension, is crucial to establish potential expansion of the disease and to substratify patients clinically. There are multiple strategies that may be taken into consideration for patients with positive lymph nodes. Nowadays therapeutic methods are generally based on observation, radiotherapy, and androgen deprivation therapy. However current guidelines are incoherent in terms of indication of the most effective management approach. Future management strategies will be expected to reach for novel diagnostic tools and therapies, such as photodynamic therapy or diagnostic imaging with prostate specific membrane antigen. Nevertheless, this heterogeneous group of men remains a vast therapeutic concern, and both clarification of the guidelines and optimal substratification of patients is required.