Purpose of Review: Prostate cancer remains the commonest nondermatological cause of cancer in Western men and the second leading cause of cancer death in these men. While low and intermediate-risk prostate cancers make up the vast bulk of prostate cancer diagnoses, it is high-risk prostate cancer that is a much larger killer. Management paradigms for such disease are changing and thus we review the current state of play with the management of these cancers and what the future might hold., Recent Findings: High-risk prostate cancer is a heterogeneous beast, with huge variations in disease severity. Hence, management of these cases must be tailored based on specific risk factors of individual patients, and the role for surgery especially in the lower end of the spectrum is increasing., Summary: The increasing use of radical extirpative surgery might negatively impact functional outcomes but are likely to prolong lives of high-risk prostate cancer sufferers, though more research from well conducted randomized controlled trials is needed to exactly define which patient subpopulations should receive which therapies, in which orders, and at what times.