Radical prostatectomy outcomes in men aged 75 or older with high-risk localized or locally advanced prostate cancer

We evaluated whether radical prostatectomy is safe and effective in elderly patients with high-risk localized or locally advanced prostate cancer. We retrospectively analyzed 757 patients at four Chinese tertiary centers (2012–2022): 201 aged 75 or older, 556 younger. Elderly patients had longer operative time (165 vs. 155 min, p = 0.002), greater blood loss (350 vs. 280 mL, p < 0.001), and more Clavien-Dindo grade III or higher complications (8.0% vs. 3.8%, p = 0.018), but 30-day mortality was 0.5%. Pathological characteristics, including stage distribution, were broadly similar. At five years, biochemical recurrence-free survival was 72% vs. 79% (hazard ratio 1.32, p = 0.021), cancer-specific survival 94% vs. 95% (hazard ratio 1.45, p = 0.203), overall survival 88% vs. 96% (hazard ratio 2.18, p < 0.001), and metastasis-free survival 91% vs. 93% (hazard ratio 1.56, p = 0.028). Most deaths in elderly patients were non-cancer related (13 of 25). Propensity matching and weighting preserved effect directions, although evidence weakened in some adjusted analyses (weighted recurrence p = 0.053; competing-risk p = 0.062). A recurrence nomogram showed modest discrimination (C-index 0.63). Radical prostatectomy is feasible in carefully selected fit older patients, but age alone should not guide decisions; comorbidity and life expectancy must be considered.