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| A systematic review of cytoreductive prostatectomy outcomes and complications in oligometastatic disease |
Andrey Morozova,Leonid Chuvalova,Mark Taratkina,b,Mikhail Enikeeva,Leonid Rapoporta,Nirmish Singlac,Eric Barretd,Elena Poddubskayae,Maria Borodinaf,Georg Salomong,Juan Gomez Rivash,Dmitry Enikeeva,i,*( )
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aInstitute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
bYoung Academic Urologists, EAU, the Netherlands
cDepartment of Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, USA
dDepartment of Urology, Institut Mutualiste Montsouris, Paris, France
eSechenov University, Moscow, Russia；f Hertsen Moscow Oncology Research Institute, Moscow, Russia
fHertsen Moscow Oncology Research Institute, Moscow, Russia
gMartini Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
hDepartment of Urology, Clinico San Carlos University Hospital, Madrid, Spain
iDepartment of Urology, Medical University of Vienna, Vienna, Austria |
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Abstract Objective: To analyze outcomes and complications of cytoreductive prostatectomy (CRP) for oligometastatic prostate cancer (PCa) in order to elucidate its role in this space. Methods: We performed a systematic literature search using three databases (Medline, Scopus, and Web of Science). The primary endpoints were oncologic outcomes. The secondary endpoints were complication rates and functional results. Results: In all studies, overall survival was better or at least comparable variable in the groups with CRP compared to no local treatment. The greatest benefit from CRP in 5-year overall survival in one study was 67.4% for CRP versus 22.5% for no local treatment. Cancer-specific survival (CSS) showed the same trend. Several authors found significant benefits from CSS in the CRP group: from 79% vs. 46% to 100% vs. 61%. CRP was a predictor of better CSS (hazard ratio 0.264, p=0.004). Positive surgical margin rates differed widely from 28.6% to 100.0%. Urinary continence in CRP versus RP for localized PCa was significantly lower (57.4% vs. 90.8%, p<0.0001). Severe incontinence occurred seldom (2.5%-18.6%). Total complication rates after CRP differed widely, from 7.0% to 43.6%. Rates of grades 1 and 2 events prevailed. Patients on ADT alone also showed a considerable number of complications varying from 5.9% to 57.7%. Conclusion: CRP improves medium-term cancer control in patients with oligometastatic PCa. The morbidity and complication rates of this surgery are comparable with other approaches, but postoperative incontinence rate is higher compared with RP for localized disease.
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Received: 23 November 2021
Available online: 20 April 2024
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Corresponding Authors:
* Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia. E-mail address: dvenikeev@gmail.com (D. Enikeev).
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Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. WoS, Web of Science.
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| Study | Study quality, LE | Imaging modality | Patient, n; age, yr | PSA, ng/mL | Gleason score before treatmenta | Mt characteristica | Stage cTa | Stage pTa | Complicationa | Functional outcomea | Oncological outcome | | Culp et al., 2014 [34]; retrospective | 7, 2b | NR | ? RP
-245; mean 72
? BT
-129; mean 72
? NLT
-7811; mean 72 | ? RPa
-<10: 115 (46.9)
-10-19: 50 (20.4)
-20-29: 17 (6.9)
->30: 32 (13.1)
-Unknown: 31 (12.7)
? BTa
-≤19: 64 (49.6)
-≥20: 55 (42.6)
-Unknown: 10 (7.8)
? NLTa
-<19: 1503 (19.2)
-≥20: 5373 (68.8)
-Unknown: 935 (12.0) | ? RP
-7: 51 (20.8)
-8: 187 (76.3)
-Unknown: 7 (2.9)
? BT
-7: 24 (18.6)
-8: 94 (72.9)
-Unknown: 11 (8.5)
? NLT
-7: 439 (5.6)
-8: 5673 (72.6)
-Unknown: 1699 (21.8) | ? RP
-M1a: 24 (9.8)
-M1b: 150 (61.2)
-M1c: 71 (29.0)
? BT
-M1a: 16 (12.4)
-M1b: 75 (58.1)
-M1c: 38 (29.5)
? NLT
-M1a: 463 (5.9)
-M1b: 5469 (70.0)
-M1c: 1879 (24.1) | ? RP
-≤cT2: 130 (53.1)
-≥cT3: 113 (46.1)
-Unknown: 2 (0.8)
? BT
-≤cT2: 91 (70.5)
-≥cT3: 20 (15.5)
-Unknown: 18 (14.0)
? NLT
-≤cT2: 4318 (55.3)
-≥cT3: 1562 (20.0)
-Unknown: 1931 (24.7) | NR | NR | NR | ? RP
-5-yr OS: 67.4%
? BT
-5-yr OS: 52.6%
? NLT
-5-yr OS: 22.5% | | Heidenreich et al., 2015 [32]; case-control | 5, 3b | ?CT, bone scan, MRI if needed | ? RP
-23; 61 (42-69)b
? ADT
-38; 64 (47-83)b | ? RPb
?135.2 (3.5-150.4)
? ADTb
?105.9 (45-195) | ? RP
-≤7: 5 (21.7)
-8: 7 (30.4)
-9: 7 (30.4)
-10: 4 (17.4)
? ADT
-≤7: 14 (37.8)
-8: 11 (29.7)
-9: 8 (21.6)
-10: 4 (10.8) | | Satkunasivam et al., 2015 [30]; retrospective | 7, 2c | NR | ? RP
-47; (73±6)d
? IMRT: 88; (74.2±6.1)d
? RT
-107; (76.4±6.3)d
? NLT
-3827; (78.2±7.2)d | ? RPd: 181±263
? IMRTd: 282±338
? RTd: 531±369
? NLTd: 590±380 | ? RP
-≤6: 5 (11)
-7: 22 (47)
-≥8: 19 (40)
-Unknown: 1 (2)
? IMRT
-≤6: 10 (11)
-7: 24 (27)
-≥8: 43 (49)
-Unknown: 11 (12)
? RT
-≤6: 8 (7)
-7: 22 (21)
-≥8: 59 (55)
-Unknown: 18 (17)
? NLT
-≤6: 167 (4)
-7: 569 (15)
-≥8: 2042 (53)
-Unknown: 1049 (27) | ? RP
-M1a: 3 (7)
-M1b: 26 (57)
-M1c: 17 (37)
? IMRT
-M1a: 3 (7)
-M1b: 26 (57)
-M1c: 17 (37)
? RT
-M1a: 4 (4)
-M1b: 72 (67)
-M1c: 31 (29)
? NLT
-M1a: 190 (5)
-M1b: 2570 (70)
-M1c: 922 (25) | ? RP
-≤cT2: 21 (45)
-≥cT3: 25 (53)
-Unknown: 1 (2)
? IMRT
-≤cT2: 63 (72)
-≥cT3: 19 (22)
-Unknown: 6 (7)
? RT
-≤cT2: 59 (55)
-≥cT3: 26 (24)
-Unknown: 22 (21)
? NLT
-≤cT2: 2121 (55)
-≥cT3: 759 (20)
-Unknown: 947 (25) | NR | NR | NR | ? RP
-3-yr OS: 73%
-3-yr CSS: 79%
? IMRT
-3-yr OS: 72%
-3-yr CSS: 82%
? RT
-3-yr OS: 37%
-3-yr CSS: 49%
? NLT
-3-yr OS: 34%
-3-yr CSS: 46%
-Follow-up: median 20 mo | | Sooriakumaran et al., 2016 [31]; retrospective | NA, 4 | NR | ? RP
-106; 64.5 (58-70)e | ? RPe: 23.5 (8.1-55.1) | ? RPe
-8.5 (8-9) | -M1a: 36 (34.0)
-M1b (≤1 Mts): 20 (18.9)
-M1b (2 Mts): 7 (6.6)
-M1b (3 Mts): 9 (8.5)
-M1b (Mts number not recorded): 34 (32.1) | -≤cT2: 67 (63.2)
-≥cT3: 39 (36.8) | -≤pT2: 23 (21.7)
-≥pT3: 83 (78.3) | -M1a: 7/36 (19.4)
-M1b: 15/70 (21.4)
-Total: 22/106 (20.8) | ? Incontinence in 3 mof
-0-1 pad/day: 38 (64.4)
-Mild (1-2 pads/d): 10 (16.9)
-Severe (≥3 pads/d): 11 (18.6) | ? CSM: 11.3% (12 /106)
? PSM: 54.3% (57/105)
? Follow-up: median 22.8 mo | | Jang et al., 2018 [23]; retrospective | 6, 3b | ?CT or MRI, and bone scan | ? RARP
-38; 65 (62-69)e
? ADT: 41; 71 (67-76)e | ? RARPe: 39 (15-84.5)
? ADTe: 50 (23.8-162.8) | ? RARP
-≤8: 26 (68.4)
-≥9: 12 (31.6)
? ADT
-≤8: 24 (58.5)
-≥9: 17 (41.5) | -M1a-b: 79 (100) | ? RARP:
-≤cT2: 5 (13.2)
-≥cT3: 33 (86.8)
? ADT:
-≤cT2: 2 (4.9)
-≥cT3: 39 (95.1) | ? RARP:
-≤pT2: 2 (5.2)
-pT3: 31 (81.6)
-pT4: 5 (13.2)
? ADT: NA | ? RARP (Clavien-Dindo score):
-1: 3 (7.9);
-2: 1 (2.6);
-3a: 1 (2.6);
-3b: 1 (2.6)
-Total: 6 (15.7).
? ADT: 11 (26.8) | ?NR | ? PSMa: 30 (78.9)
? CRP is a significant predictor of PFS and CSS (PFS: HR 0.388, p=0.003; CSS: HR 0.264, p=0.004)
? Follow-up: median 40 mo | | Poelaert et al., 2017 [35]; multicenter prospective | 5, 3b | ?CT, pelvic MRI, and bone scan | ? CRP
-17; (64±8)d
? SoC
-29; (72±10)d | ? CRPb
?16 (4.6-75);
? SoCb
?156 (5.2-3092) | ? CRP
-≤7: 4 (24)
-8: 5 (29)
-≥9: 8 (47)
? SoC
-≤7: 2 (6.7)
-8: 8 (28)
-≥9: 19 (66) | | Steuber et al., 2017 [25]; prospective case-control | 5, 3b | Bone scan, CT, or MRI | ? CRP
-43; median 65
? ADT
-40; median 70 | ? CRP: median 29.0
? ADT: median 42.5 | ? CRP
-7b: 13 (30.2)
-8: 13 (30.2)
-9: 15 (34.9)
-10: 2 (4.7)
? ADT
-≤7a: 1 (2.5)
-7b: 5 (12.5)
-8: 13 (32.5)
-9: 16 (40.0)
-10: 5 (12.5) | | Leyh-Bannurah et al., 2017 [24]; retrospective | 8, 2b | NR | ? RP
-313; 63 (58-67)e
? RT
-161; 68 (60-73)e
? NLT
-13 218; 72 (63-80)e | ? RP and RTa,g
-≤20: 128 (74)
->20: 46 (26)
? ADTa
-≤20: 864 (17)
->20: 4249 (83) | ? RP
-6: 41 (13)
-7: 105 (34)
-8: 145 (46)
-Unknown: 22 (7)
? RT
-6: 30 (19)
-7: 47 (29)
-8: 72 (45)
-Unknown: 12 (7.5) | ? RP
-M1a: 35 (11)
-M1b: 222 (71)
-M1c: 56 (18)
? RT
-M1a: 19 (12)
-M1b: 103 (64)
-M1c: 39 (24)
? ADT
-M1a: 800 (6)
-M1b: 9478 (72)
-M1c: 2940 (22) | ? RP
-≤cT2: 280 (89.5)
-≥cT3: 33 (10.5)
? RT:
-≤cT2: 137 (86.1)
-≥cT3: 24 (14.9)
? ADT
-≤cT2: 10597 (80.2)
-≥cT3: 2621 (19.8) | NR | NR | NR | ? RP and RT (n=474): lower CSM (HR=0.40, 95% CI 0.32-0.50) vs. NLT (n=1896)h
? RP (n=161): lower CSM (HR=0.59, 95% CI 0.35-0.99) vs. RT (n=161) | | Kim et al., 2018 [29]; retrospective, cohort, multicenter | 7, 2c | NR | ? CRP (metastatic PCa)
-68; 64.3
(33-80)c
? RP ( localized PCa)
-598; 63.5 (39-82)c | ? CRP: 10.10 (0.01-352.00)c
? RP: 6.50 (0.12-104.00)c | ? CRPi
-≤7: 25 (37.9)
-8: 19 (28.8)
-9: 20 (30.3)
-10: 2 (3.0)
? RPi
-≤7: 471 (80.1)
-8: 73 (12.4)
-9: 39 (6.6)
-10: 5 (0.9) | ? CRPi
-M1: 23 (33.8)
-N1: 45 (66.2)
-N1M0: 45 (66.2)
-N0M1: 20 (29.4)
-N1M1: 3 (4.4)
? RP: NA | ? CRPi
-cT2: 17 (25)
-cT3: 42 (61.8)
-cT4: 9 (13.2)
? RPi
-cT2: 525 (88.7)
-cT3: 62 (10.5)
-cT4: 5 (0.8) | ? CRPi
?≤pT2: 15 (23.4)
?pT3: 39 (60.9)
?pT4: 10 (15.6)
? RPi
≤pT2: 396 (66.9) pT3: 187 (31.6)
?pT4: 9 (1.5) | ? CRP (Clavien-Dindo score)
-0: 62 (91.2)
-1: 2 (2.9)
-2: 1 (1.5)
-3а: 0
-3b: 3 (4.4)
-4≥: 0
-Total: 6 (8.8)
? RP (Clavien-Dindo score)
-0: 563 (94.2)
-1: 19 (3.2)
-2: 3 (0.5)
-3а: 5 (0.8)
-3b: 6 (1)
-4а: 2 (0.3)
-4b≥: 0
-Total: 35 (5.9) | ? CRP
-Urinary continence significantly lower (57.4% vs. 90.8%, p<0.0001) | ? CRP
-PSMa: 43 (63.2)
? RP
-PSMa: 112 (19) | | Heidenreich et al., 2018 [33]; retrospective, multicenter | NA, 4 | ?CT, bone scan, or MRI if needed | ? RP
-113; 60.2 (42-69)e | ? 34.2 (0.1-357.4)c | ? RP
-6: 4 (3.5)
-7: 18 (15.9)
-8: 42 (37.2)
-9: 40 (35.4)
-10: 9 (7.9) | ? Low volume (≤3 Mts)
-88 (77.9)
? High volume (≥4 Mts)
-25 (22.1) | NR | -pT2: 21 (18.6)
-pT3a/b: 76 (67.3)
-pT4a: 16 (14.2) | ? Clavien-Dindo score
-1: 13 (11.5)
-2: 14 (12.4)
-3a: 5 (4.4)
-3b: 6 (5.3)
-4-5: 0
-Total: 38 (33.6) | ? Incontinence within 12 mo
-No: 77 (68.1)
-Mild (1-2 pads/day): 20 (17.7)
-Severe (>2 pads/day): 16 (14.2) | ? 3-yr OS: 87.6%
? 5-yr OS: 79.6%
? CRFS: 72.3 mo
? Symptomatic local relapse: 0
? BRFS:
-PSA <8.0 ng/mL: 78%
-PSA >8.0 ng/mL: 32%
? PSMa: 42 (37.2)
? Follow-upc: 53.6 (13-96) mo | | Lan et al., 2019 [27]; retrospective | 6, 3b | CT, bone scan, or MRI if needed | ? CRP
-35; (67.8±7.2)d
? ADT
-76; (71.2±7.7)d | ? CRPd:
?90.4±152.8
? ADTd:
?502.9±806 | ? CRP
-≤7: 27 (77.2)
-8: 6 (17.1)
-≥9: 2 (5.7)
? ADT
-≤7: 27 (34.6)
-8: 27 (34.6)
-≥9: 23 (29.5)
-Unknown: 1 (1.3) | ? Bone Mts (≤5 Mts)
-М1b: 111 (100)
-Excluded: visceral metastases | ? CRP
-≤cT2: 24 (68.6)
-≥cT3: 8 (22.9)
-Unknown: 3 (8.6)
? ADT
-≤cT2: 14 (18.4)
-≥cT3: 32 (42.1)
-Unknown: 30 (39.5) | ? CRP
-pT2: 15 (42.9)
-pT3: 16 (45.7)
-pT4: 4 (11.4)
? ADT: NA | NR | NR | ? CRP
-3-yr PFS: 42.7%
-5-yr PFS: 19%
-3-yr CSS: 90.8%
-5-yr CSS: 63.6%
-CSMa: 4 (11.4)
-PSMa: 10 (28.6)
-CPFSe: 35 (10-49) mo
-Follow-up: mean 36.9 mo
? ADT
-3-yr PFS: 27%
-5-yr PFS: 21%
-3-yr CSS: 87.9%
-5-yr CSS: 74.9%
-CSM: 11 (14.5%)
-PFSe: 21 (10-49) mo;
-Follow-up: mean 39.2 mo | | Yuh et al., 2019 [26]; prospective | NA, 4 | Bone scan, CT, or MRI | ? RP
-32; 64 (50-73)b | ? 75.5 (5-418)c | -≤7: 11 (34.4)
-8: 20 (62.5)
-Not available result: 1 (3.1) | -N1M0: 7 (21.9)
-N1M1a: 3 (9.4)
-N1M1b: 7 (21.9)
-N0M1a: 0
-N0M1b: 15 (46.9) | -cT1: 6 (18.8)
-cT2: 13 (40.6)
-cT3: 13 (40.6) | -pT2: 6 (18.8)
-pT3a: 6 (18.8)
-pT3b: 20 (62.5) | ? Clavien-Dindo score
-1: 5 (15.6)
-2: 3 (9.3)
-3: 0
-4: 1 (3.1)
-5: 1 (3.1)
-Total: 10 (31.3) | ? Incontinence within 6 mo
-No: 16 (50)
? Mean score decreased from 11.5 preoperatively to 4.7 following surgery (p= 0.0018) | ? PSMa: 21 (65.6%) | | Simforoosh et al., 2019 [28]; prospective | 7, 3b | CT, MRI, bone scan, or PET-PSMA if needed | ? CRP
-26; (61.5±7.7)d
? NLT
-23; (64.6±6.2)d | ? CRPd: 108±73
? NLTd: 84±61 | ? CRP
-≤7: 1 (3.8)
-8: 2 (7.6)
-9: 18 (69.2)
-10: 5 (19.2)
? NLT: NR | ? CRP
-Low volume bone (≤5 Mts): 10 (38.5)
-High volume (≥6 Mts): 16 (61.5)
? NLT
-Low volume bone (≤5 Mts): 9 (39.1)
-High volume (≥6 Mts): 14 (60.9) | NR | ? RP
-pT2b: 1 (3.8)
-pT2c: 1 (3.8)
-pT3a: 1 (3.8)
-pT3b: 22 (84.6)
-pT4: 1 (3.8)
? NLT: NA | ? CRP (Clavien-Dindo score)
-1-3: 7 (26.9)
? NLT: 9 (38.9) patients required intervention | ? CRP ( incontinence)j
-No: 22 (84.6)
-Stress: 3 (11.5) | ? CRP
-CSMa: 6 (23.1)
-BRa: 9 (34.6)
-PSMa: 26 (100)
-Follow-up: median 19.2 mo
? NLT
-CSMa: 8 (34.8)
-BRa: 17 (73.9)
-Follow-up: median 22.8 mo | | Knipper et al., 2020 [36]; retrospective | 6, 2c | Bone scan, CT, or MRI | ? RP
-78; 64 (59-69)e
? RT
-410; 68 (63-73)e, from STAMPEDE arm H (low metastatic burden) | ? RP: 35 (13-55)e
? RT: 55 (23-138)e | ? RP
-7: 18 (23)
-8-9: 60 (77)
? RT
-7: 84 (20)
-8-9: 308 (75)
-Unknown: 18 (4) | ? RP
-M1b: 78 (100)
? RT
-M1a: 82 (20)
-M1b: 311 (76)
-M1c: 17 (4) | ? RP
-≤cT2: 58 (74)
-≥cT3: 16 (21)
-Tx: 4 (5)
? RT
-≤cT2: 39 (10)
-≥cT3: 355 (87)
-Tx: 16 (4) | ? RP
-pT2: 6 (8)
-pT3: 67 (86)
-pT4: 5 (6).
? RT: NA | ? RP (Clavien-Dindo score)
-1: 6 (8)
-2: 12 (15)
-3a: 6 (8)
-3b: 8 (10)
-4: 2 (3)
-Totalk: 34 (43.6) | ? RP (continence at 1-yr follow-up)
-0-1 pad/day): 28 (36)
-1 pad/day): 10 (13)
-Unknown: 40 (51) | ? RP (3-yr follow-up)
-OS: 91%
-PFS: 63%
-MPFS: 63%
-CSS: 92%
? RT (3-yr follow-up)
-OS: 81%
-PFS: 63%
-MPFS: 67%
-CSS: 86% |
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Outcomes and complications of cytoreductive prostatectomy and other treatment approaches in patients with oligometastatic PCa.
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