Based on the clarity of your comments, you already know that a Gleason 9 is considered very high risk. (May also be aggressive, the PSMA PET scan will determine this.)

> Just out of curiosity, is your Gleason 9 a 4+5 or a 5+4?

NCCN guidelines recommend two options. (See attached NCCN guidelines chart.)

> For very high risk disease, with external radiation NCCN guidelines recommends both ADT + ARPI. (Doublet therapy is not uncommon for Gleason 9 & 10.)

> Did your MRI report or biopsy report mention anything about: cribriform pattern, extracapsular extension, seminal vesicle invasion, perineural invasion or intraductal carcinoma?

As for your treatment options —>
One of the understandings I had with my doctors was that (at 65y) quality-of-life and successful treatment were of equal priority for me. That set the basis for us working together and ultimately agreeing on an appropriate treatment plan.

> You’ll have to establish your own priorities in making this decision.

With success rates comparing surgery with external radiation for localized prostate cancer being statistically equivalent, it all comes down to side-effects you’re willing to deal with and quality-of-life you want afterwards (or as a paper I read put it, “… the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer.”).

> Take the time to figure out for yourself your priorities and what’s best for you.

If you choose external radiation, using a rectal spacer is a must, with SpaceOAR, Barrigel, and BioProtect being the options.

> Barrigel preferred to SpaceOAR because it is sculptable.
> SpaceOAR Vue preferred to the standard SpaceOAR Hydrogel because it contains approximately 1% iodine bound to the hydrogel to be more visible under CT scan.
> BioProtect is the latest of the rectal spacers (recently approved for use in 2023).

(I had 28 sessions of proton radiation (+ SpaceOAR Vue) and 6 months (two 3-month injections) of hormone therapy, for my localized, PSA of 7.976, Gleason 7(4+3). PSA is now 0.366.)