Although the prostate specific antigen (PSA) era has altered the clinical and demographic characteristics of men with newly-diagnosed prostate cancer, the impact on patients with high risk disease has been less predictable. We have long advocated aggressive surgical resection for patients with high risk prostate cancer at the Mayo Clinic, including patients with clinical T3 tumors, and have reported our results as well of radical prostatectomy with adjuvant hormonal therapy in the setting of lymph node positive disease. At the same time, multiple predictive models have been developed to assess the risk of disease progression following definitive therapy for prostate cancer. One such model is pretreatment risk group stratification, based on patients' PSA at diagnosis, biopsy Gleason score, and clinical stage. Here, we will review our institution's experience with surgical treatment for men with high risk prostate cancer, and will address the benefits and potential pitfalls of the pretreatment risk group classification model for high risk patients.