Background <p>Robot-assisted radical prostatectomy using the Retzius-sparing approach (RS-RARP) is increasingly adopted, yet evidence regarding outcomes in men aged ≥ 75 years remains extremely limited.</p> Objective <p>This study evaluated perioperative, oncological, and functional outcomes of RS-RARP in elderly patients.</p> Methods <p>A total of 608 men who underwent RS-RARP between 2016 and 2023 were included. Patients were divided into two groups: &lt;75 years (<i>n</i> = 548) and ≥ 75 years (<i>n</i> = 60). Preoperative characteristics, surgical parameters, complications, pathological findings, and continence status up to 12 months were compared.</p> Results <p>Men aged ≥ 75 years presented more often with larger prostates, higher biopsy ISUP grades, and more intermediate/high-risk disease. Non–nerve-sparing procedures were more frequently performed in the elderly group and operative time, blood loss, hospital stay and complication rates were similar between the two groups. The rate of early urinary continence recovery was lower among older patients, but by 12 months continence rates were nearly identical. Elderly patients showed more advanced pathological tumor stages, more PSA persistence and a higher need for adjuvant hormonal therapy, while rates of positive surgical margins and biochemical recurrence were comparable.</p> Conclusions <p>RS-RARP can be safely offered to selected patients aged ≥ 75 years without compromising perioperative safety or oncological control. Despite delayed continence recovery, one-year functional outcomes are equivalent, supporting RS-RARP as a viable treatment option for appropriately chosen elderly men with localized prostate cancer.</p>