Outcomes after cytoreductive radical prostatectomy for de novo metastatic hormone-sensitive prostate cancer: survival and time to treatment intensification in a retrospective cohort

Purpose: To evaluate whether cytoreductive radical prostatectomy (CRP) confers benefit beyond contemporary systemic therapy in men with de novo metastatic hormone-sensitive prostate cancer (mHSPC). Methods: Single-center retrospective cohort (2014–2022) comparing CRP plus systemic therapy versus systemic therapy alone. Primary endpoints were overall (OS) and cancer-specific survival (CSS); secondary endpoints were time to treatment intensification (“no-intensification survival”) and post-intensification progression-free survival (PFS). Kaplan–Meier/log-rank and Cox models were used; competing-risk methods estimated subdistribution hazard ratios (sHR) for intensification. Propensity-score matching (1:2; caliper 0.1) tested robustness. Results: Among 164 patients, 58 received CRP and 106 no local therapy; median follow-up was 30.6 months (36.2 among survivors). In the unmatched cohort, 5-year OS was 70.2% with CRP versus 35.4% without (univariable HR 0.24; multivariable HR 0.40; p=0.006), and 5-year CSS was 83.8% versus 49.6% (HR 0.20; p<0.001). CRP prolonged no-intensification survival (2-year 56.6% vs 33.6%; HR 0.46; log-rank p<0.001) and lowered the cumulative incidence of intensification (sHR 0.52; Gray’s p=0.003). Post-intensification PFS was similar (HR 0.89; p=0.67). After matching (CRP n=35; non-CRP n=51), 5-year OS was 55.0% versus 41.0% (p=0.027) and CSS 75.0% versus 54.0% (p=0.021). Conclusion: CRP integrated with systemic therapy was associated with improved OS/CSS and delayed treatment intensification without affecting outcomes after intensification, supporting CRP as a potential component of multimodal management in selected men; randomized trials are warranted.