[When is surgical treatment indicated in metastatic prostate cancer and what is the scientific rationale?]

Recent improvements in imaging diagnostics has led to a rising incidence of oligometastatic prostate cancer and, most notably, an increasing incidence of nodal-only biochemical recurrences. In this clinical setting, systemic therapy is still the treatment of choice. However, there is increasing evidence for surgical approaches in this challenging clinical setting.

In this comprehensive review article, current evidence regarding surgical approaches of primary nodal metastases, nodal-only biochemical recurrence following radical prostatectomy, and osseous metastatic prostate cancer will be discussed.

If nodal metastasis is clinically suspected, a significant survival benefit was observed in retrospective studies if radical prostatectomy and extended pelvic lymphadenectomy was performed within a multimodal therapeutic setting. Salvage lymphadenectomy as a therapeutic option for nodal-only biochemical recurrence is clinically feasible and can postpone systemic therapy significantly. However, since most patients do not have a lasting PSA response, a survival benefit of this therapeutic approach is questionable based on current evidence. Regarding osseous metastatic prostate cancer, the surgical approach has an inferior position compared to conservative management and radiotherapy.

Evidence regarding a surgical approach towards oligometastatic prostate cancer is increasing. However, current evidence is mainly based on retrospective studies that were conducted in the pre-PSMA-PET/CT era.