Objective To analyze the early efficacy and associated risk factors of neoadjuvant hormonal therapy（NHT） for high-risk prostate cancer（hrPC）. Methods From January 2020 to January 2023，a total of 151 patients with hrPC who underwent radical prostatectomy（RP） were included in this study. Of these 151 patients，70 were assigned to the NHT group and received luteinizing hormone-releasing hormone analogue（LHRH-A） combined with nonsteroidal antiandrogen agent before RP to maximize androgen blockade. Alterations in prostate volume and prostate specific antigen（PSA） levels were examined post-treatment in the NHT group. The other 81 patients were assigned to the control group and underwent direct RP. Perioperative parameters，including surgical time，intraoperative bleeding，drainage tube retention time，and length of hospital stay，as well as postoperative positive surgical margin（PSM） rate and decrease in Gleason score were compared between the two groups. In addition，the risk factors associated with PSM rate were also analyzed. Results PSA levels and prostate volume were significantly decreased after treatment in the NHT group，with the extent of PSA decrease correlated with the duration of treatment（P<0.05）. Compared with the control group，the NHT group had a shorter surgical time，a lower postoperative PSM rate，and a greater decrease in Gleason score than the control group（all P<0.05）. However，there were no significant differences in intraoperative bleeding，drainage tube retention time，and length of hospital stay between the two groups（all P>0.05）. PSA level was a risk factor for PSM rate in both groups. Conclusion NHT can reduce PSA levels and prostate volume，rendering hrPC patients more amenable to surgery and making RP possible for those who were previously deemed unsuitable for surgery. In addition，NHT can lower PSM rate and decrease Gleason score. PSA value is a risk factor for PSM.