I am a big advocate of radiation treatment (RT) over radical prostatectomy (RP). An RP causes a lot of damage that is hard to recover from. The surgeons talk about new nerve sparing techniques but the reality is that nerves are always damaged with an RP. You can easily become permanently incontinent after an RP as the prostate provides the bulk of the sphincter muscle to control urine flow. Regardless of how good your surgeon is, and no matter how many Kegel exercises you do, if you are lucky enough not to have permanent incontinence, you will still very likely experience urine leakage when you cough, sneeze, lift heavy objects or run. Permanent ED and very compromised sexual function is very common after an RP. As you read through cases on this forum, you will see that RP guys have a lot of incontinence and ED issues, far more than what RT guys experience.

In addition, the RP guys also experience a lot of recurrence causing them to have to use radiation as well. RP guys have a 30% recurrence rate overall but that climbs to 50% and 60% when the patient has Gleason scores of 8 and 9 respectively. Most surgeons simply do not emphasize enough how likely a recurrence is after an RP. Enter your data in the MSK nomogram here https://www.mskcc.org/nomograms/prostate/pre_op if you would like to see your odds of recurrence after an RP.

I believe that the reason that there is such a high recurrence rate after an RP is that there are microscopic escapes of cancer cells outside of the prostate that occur before the RP is even performed. These small cancer cell escapes can't yet be detected by our best scans like the PSMA PET scan. It is still too easy for some cancer cells to lurk in lymph nodes or seminal vesicles without being detected. This is especially true when you have a genetic predisposition like BRCA2, high Gleason scores and/or a high Decipher score. Extracapsular extensions and lesions broadly abutting the prostate capsule also increase the risk that some escape has occurred.

Having so called "clean margins" after an RP is really not much assurance that all the cancer was removed. With radiation treatment and possibly some ADT treatment if needed, cancer in the prostate gland itself and cancer as yet undetected in microscopic escapes can be killed both in the gland itself and the greater pelvic region.

Ideally, we all want to have a treatment plan that let's us be one and done with the least side effects possible and never have to deal with prostate cancer again. There are occasional side effects from radiation and there are some recurrences as well, but overall, as you read through scores of cases on this forum, I think you will find radiation yielding the best overall outcomes in terms of fewest side effects and less recurrences of cancer.