We hypothesized that reducing tumor burden through cytoreductive radical prostatectomy (CRP) would improve outcomes in patients with synchronous metastatic hormone-sensitive prostate cancer compared to medication treatment alone. This study aimed to evaluate the potential benefits of CRP and identify which patient groups may benefit most from this approach.

This retrospective study included patients initially diagnosed with stage 4B metastatic hormone-sensitive prostate cancer between 2014 and 2022 at a single hospital. Baseline variables included age, ECOG performance status, Charlson Comorbidity Index, Prostate-Specific Antigen, biopsy grade group, and disease volume (classified as low or high). To balance baseline differences between the CRP and control groups, inverse probability of treatment weighting (IPTW) was applied. Kaplan-Meier survival curves were used to assess outcomes, and Cox proportional hazards models estimated hazard ratios (HR) with 95% confidence intervals (CI).

A total of 164 patients were analyzed, with 58 in the CRP group and 106 in the control group. The mean follow-up was 36 months. At baseline, patients in the CRP group had significantly better ECOG status, CCI, age, PSA, biopsy grade group, and volume. After IPTW adjustment, Cox regression analysis showed that high-volume disease was significantly associated with worse outcomes across mCRPC-free survival, cancer-specific survival (CSS), and overall survival (OS), while other covariates showed no significant impact on these outcomes. In Cox regression model comparing the CRP and the control group, mCRPC-Free Survival: CRP significantly delayed mCRPC onset (HR = 0.53, 95% CI: 0.30–0.96, p<0.001). CSS: CRP reduced cancer-specific mortality (HR = 0.44, 95% CI: 0.20–0.97, p<0.001). OS: CRP significantly improved overall survival (HR = 0.46, 95% CI: 0.24–0.87, p<0.001).

CRP improved outcomes by delaying mCRPC progression, reducing cancer-specific mortality, and enhancing overall survival compared to medication alone. Patients with low-volume disease appeared to benefit more from CRP, highlighting the importance of disease burden at diagnosis in guiding treatment decisions. These findings support the role of CRP in improving survival outcomes in patients with synchronous stage 4B mHSPC.