Cytoreductive Radical Prostatectomy in Oligometastatic Prostate Cancer and the Role of the Robotic Platform: A Narrative Review.

Background

Oligometastatic prostate cancer (OMPC) comprises biologically and clinically distinct states with a limited number of detectable metastases. Improved systemic therapy and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) have intensified interest in treating the primary tumor.

Methods

In this narrative review we searched PubMed/MEDLINE from inception to 1 July 2026, reviewed current guidelines, and searched ClinicalTrials.gov, the ISRCTN registry and the EU Clinical Trials Register for ongoing surgical studies, prioritizing randomized trials, prospective studies, PSMA PET-staged cohorts, systematic reviews, guidelines, and studies of perioperative, functional and patient-reported outcomes.

Results

Registry and institutional data generated the hypothesis that cytoreductive prostatectomy improves outcomes but are vulnerable to selection bias; prospective and PSMA PET-staged cohorts established feasibility. The phase II trial by Dai and colleagues supported radical treatment of the primary tumor but combined surgery and radiotherapy. RAMPP provided the first prostatectomy-specific randomized signal, with lower 5-year cancer-specific mortality after radical prostatectomy plus best systemic therapy than after systemic therapy alone (13% versus 23%; hazard ratio 0.39, 95% confidence interval 0.16-0.98), but accrual ended early, clinical progression was similar, overall survival was not significantly improved, systemic therapy predated contemporary intensification, and major surgery-related complications occurred in 14%. A randomized phase II trial with a predominantly surgical local-therapy arm found no progression-free or overall survival benefit, so randomized evidence is mixed. All randomized evidence concerns radical prostatectomy or local treatment irrespective of surgical approach; no trial has tested a robot-specific oncologic effect. Guidelines recommend prostate radiotherapy for selected low-volume de novo metastatic disease and restrict surgery to clinical trials.

Conclusions

Cytoreductive prostatectomy, delivered mostly as robot-assisted radical prostatectomy (RARP), is feasible and may improve local control while providing complete pathology, but it remains investigational; the robotic approach is the surgical platform, not a modality with distinct oncologic efficacy. Appropriate use requires expert-center surgery, modern staging, guideline-concordant systemic therapy, multidisciplinary selection, transparent counseling and, preferably, trial participation. Future trials must establish whether prostatectomy adds meaningful benefit beyond modern systemic therapy, prostate radiotherapy and metastasis-directed treatment, while measuring morbidity, continence and quality of life.