Role of Radical Prostatectomy in Oligo-Metastatic Hormone-Sensitive Prostate Cancer: A Systematic Review and Meta-Analysis

Introduction and Aims: Androgen deprivation therapy (ADT) with systemic anti-cancer treatment (SACT) ± palliative radiotherapy (pRT) is the current standard of care for Oligo-metastatic hormone-sensitive prostate cancer (o-mHSPC). Cytoreductive radical prostatectomy (cRP) has gained interest in this group of patients, with potential benefits including reduced tumour burden and a lower risk of local events from disease progression. In this review, we compare both survival outcomes and local event rates between cRP and upfront ADT ± SACT. Methods: All randomised trials and observational studies comparing cRP with standard treatment (ST), which we defined as ADT ± SACT for o-mHSPC, were included in the review. The study protocol was registered in PROSPERO (CRD42024516586), and the review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The databases searched included Embase, Medline, Cochrane Library, PubMed, and Web of Science. A risk of bias assessment was performed for the included studies as recommended by the Cochrane Handbook of Systematic Reviews and Interventions. The primary outcome measures were Overall Survival (OS), Cancer-Specific Survival (CSS), Progression-free Survival (PFS), Castrate-resistant Prostate Cancer-free Survival (CRPC-FS), and local complication rates. The secondary outcome measures were complication rates and functional outcomes post-cRP. Results: A total of 5130 studies were identified for this review (5119 by database searching and 11 through manual searching). Eight studies were included in the review, comprising 611 patients. cRP was identified to have superior OS (HR: 0.56 (95% CI: 0.34–0.92), I2 = 0%, p = 0.02 (very low certainty)) and CSS (HR: 0.27 (95% CI: 0.15–0.47), I2 = 0%, p < 0.0001 (very low certainty)). The PFS (HR: 0.67 (95% CI: 0.34–1.33), I2 = 58%, p = 0.25 (very low certainty)) and CRPC-FS (HR: 0.67 (95% CI: 0.32–1.43), I2 = 57%, p = 0.30 (very low certainty)) were similar between the two groups. The rates of local events were significantly lower in patients undergoing cRP (RR 0.27 (95% CI: 0.13–0.59), I2 = 17%, p = 0.001 (low certainty)). The rates of Clavien–Dindo (CD) grade 3 or higher complications ranged from 0% to 13.1%. Additionally, the reported continence rates ranged from 81.5% to 91.3%. The review is limited by the lack of a uniform definition for o-mHSPC and the predominance of low-quality, heterogeneous studies. Despite mitigation strategies, the overall certainty of evidence remains very low per GRADE assessment. Conclusion: cRP significantly reduces local event rates compared with ST and offers comparable PFS and CFPC-FS, with superior OS and CSS in the cRP arm compared to the ST arm in patients with o-mHSPC. However, there is a paucity of high-quality literature on this subject. Ongoing randomised controlled trials may soon clarify the role of cRP in the context of o-mHSPC concerning survival benefits.