In patients with lymph node-positive and metastatic prostate cancer there is currently no consensus about the best possible management. Multimodal approaches including systemic and local treatment have shown to improve survival. However, the role of radical prostatectomy (RP) is currently unclear. While treatment of the primary tumor is recommended in highly selected lymph node-positive prostate cancer patients, no prospective data exist to support resection of the primary tumor in metastatic patients as a treatment modality to improve overall survival. However, recent observational studies have suggested a survival benefit after prostate tumor cytoreduction. This article reviews existing evidence on the role of RP in lymph node-positive and metastatic prostate cancer patients.