•The real challenge during a radical prostatectomy is establishing the balance between well spared neurovascular bundles and tumor-free surgical margins especially in men requesting to keep their potency.•There are only very few papers published on Neurosafe (NS) addressing the relationship of nerve sparing with the preoperative imaging incorporating especially the Ga-PSMA PET/CT together with multiparametric magnetic resonance imaging.•NS led to more preserved bundles with less positive surgical margins.•NS was especially useful in patients with D'Amico high-risk disease and preoperative extracapsular extension suspicion in imaging together. We aimed to analyze the effect of preoperative risk assessment including Ga-68 PSMA PET and multiparametric magnetic resonance imaging (mpMRI) on nerve sparing practices, positive surgical margin (PSM) rates and oncological outcomes based on a comparison between patients underwent RARP with and without Neurosafe (NS). Patients underwent RARP with NS (RARP-NS) or without (RARP-only) NS retrospectively evaluated. Suspicion for extracapsular extension on mpMRI and/or Ga-68 PSMA PET was recorded as i(imaging)T3. NS was performed according to the Martini-Klinik technique. PSM at preserved bundle side were called PSM at region of interest (ROI) while the others were elsewhere. A total of 208 patients (90 in RARP-NS, 118 in RARP-only groups) were included. Preoperatively the RARP-only group showed significantly higher mean PSA (p = .01) and PIRADS 5 (p = .002) findings and had more D'Amico high risk (DAHR) patients (p = .08). The overall PSM rates for pT2 versus pT3 disease were 7.5% versus 21.6 and 15.6% versus 55% in RARP-NS and RARP-only groups, respectively. NS resulted in more bilaterally preserved bundles (81.1% vs. 66.3%) and less PSM at the ROI (3.3% vs. 23.4%) than RARP-only group. NS outperformed RARP-only in all clinical settings had its highest differential benefit in more bilateral nerve sparing and less PSM at ROI in patients with both DAHR and iT3 disease. BCR rates were 2.2% and 2.5% for RARP-NS and RARP only groups, respectively (p = .4). One patient in RARP-NS and 9 in RARP-only groups had PSA persistence (p = .02). RARP-NS led to more preserved bundles with less PSM. It was especially useful in DAHR patients with preoperative extracapsular extension suspicion in imaging simultaneously. Preoperative individual risk assessment together with appropriate imaging incorporating Ga-68 PSMA PET is very important in decision-making for the extent of the nerve sparing and keeping the margins tumor-free during a RARP. Neurosafe procedure led to more preserved keeping the margins tumor-free during a RARP. Neurosafe procedure led to more preserved and preoperative extracapsular extension suspicion in imaging together.