Octogenarians are frequently considered “low priority” candidates for surgery, despite mounting evidence that advancing age is associated with a higher prevalence of high-grade and locally advanced disease. In practice, many of these men are funnelled towards external beam radiotherapy combined with prolonged androgen deprivation therapy (ADT). This strategy often trades cancer control for long-term systemic morbidity. The consequences of castration—cardiovascular disease, frailty, cognitive decline, and loss of independence—may be particularly consequential in older patients, and testosterone recovery after extended ADT is often incomplete or absent.
Surgery, by contrast, continues to be perceived as excessively morbid in this age group. However, the evolution of minimally invasive and robotic techniques has fundamentally altered the risk profile of radical prostatectomy. Moreover, while urinary continence remains a critical quality-of-life outcome, sexual function is often a lesser concern for octogenarian men, reframing the balance of postoperative trade-offs compared with younger patients.
In this multicentre experience, we report outcomes of robotic-assisted radical prostatectomy in 30 carefully selected men aged 80 years and older. Perioperative morbidity was low and comparable to contemporary RARP series in younger populations. Continence outcomes were inferior to those of younger cohorts but remain clinically acceptable: at 12 months, 57% of patients were pad-free, a further 13% used a safety pad, and 17% required a single pad per day for mild incontinence. Sexual function outcomes were not systematically recorded, reflecting their limited relevance to this population.
Perhaps most striking is the underlying disease biology. Half of patients harboured high-grade disease (ISUP Grade Groups 4–5), and nearly three-quarters had locally advanced tumours (≥pT3). Positive surgical margins occurred in 21% overall, with no margin positivity in organ-confined disease. Although biochemical recurrence was observed in 11 patients, only seven required additional treatment. With a median follow-up of 30.5 months, 87% of patients remain free from ADT—a meaningful outcome in a population often consigned to lifelong hormonal therapy.
As populations age, the reflexive exclusion of octogenarians from surgical consideration deserves re-examination. This study challenges the notion that radical prostatectomy is inappropriate in older men and suggests that, for selected patients, robotic surgery may offer oncologic control while preserving autonomy and avoiding the cumulative toxicity of long-term ADT. Chronological age alone should not dictate therapy; biology, physiology, and patient priorities matter more.
Written by: Luka Flegar,1,2 Weiwei Shi,1 Henry Y. C. Pan,1,3 Marta Alves Santiago,1 Benjamin C Thomas,1,3,4 Nathan Lawrentschuk,1,3,4,5 Daniel Moon,3,4 Philip Dundee,1,3,4,6,7
- Department of Urology, The Royal Melbourne Hospital, 300 Grattan St, Parkville, 3052, Victoria, Australia.
- Department of Urology, University of Heidelberg, Heidelberg, Germany.
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia.
- Epworth Healthcare, Melbourne, Victoria, Australia.
- EJ Whitten Prostate Cancer Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia.
- Australian Prostate Centre, North Melbourne, Victoria, Australia.
- St Vincent's Private Hospital, Fitzroy, Victoria, Australia.