Surgery or Radiation?

avall, you've found one of the best.
You might consider radiation. Near UCI is Lennar City of Hope Cancer Center. They have one of the few Viewray Meridian radiation delivery systems. It uses MRI during the radiation treatment. You likely know that radiation is whole prostate. The treatment protocol is 5 treatments. It is a much easier treatment with no catheter for days after. Dr Percy Lee 949-671-4673 They won't schedule zoom appointments.
Amar Kishan has a compelling video about the MRI guided treatment. He is at UCLA, but without an operable delivery machine. He is another excellent physician. You might consider a zoom with him. 310-825-9776
q=mridian+viewray+kishan+video&oq=mridian+viewray+kishan&gs_lcrp=EgZjaHJvbWUqBwgBECEYoAEyBggAEEUYOTIHCAEQIRigATIHCAIQIRigATIHCAMQIRigAdIBCTIwMzI2ajBqOagCALACAA&sourceid=chrome&ie=UTF-8
Alternatively you might consider Proton treatment which would be 24 to 28 treatments. I'd suggest looking at CA Proton. Dr. Rossi is said to have treated the most prostate patients of anyone, anywhere.
in your situation I would read the CA Proton website https://www.californiaprotons.com/ Rossi has a video. If you feel interested, schedule an appointment with him. He will consult by zoom.
It is best if you have consultation for each type of treatment even though it will be impossible to determine which would be most effective.
I can recommend CA Proton. They are friendly and attentive.

Lennar City of Hope is a new hospital. Treatment there would be the easiest. I can recommend it.
Anesthesia can be harder on our older brains. Either type of radiation requires no sedation. The treatments are quick and painless.
I'm happy to answer any questions. I've been around, but have no medical degrees.

What an interesting conundrum. You have reached 88, you still identify yourself as fit and healthy, yet you have been diagnosed with advanced prostate cancer (in the prostate.) And you've already found this group!
I plugged wonderful health and an age of 79 into this life expectancy calculator and it calculated 7.1 years. https://www.blueprintincome.com/tools/life-expectancy-calculator-how-long-will-i-live/ (At age 85 it calculated 6.4 years, and it didn't accept ages beyond 85.)
The point I'm making, if any, is that you have a fairly short remaining life span regardless. So while your treating MD may offer you treatment, they may well not recommend it. Most people with PC make it 15 years (w/out respect to age) and even if your advanced biopsies indicate your cancer could spread sooner, treating the cancer probably will not extend your life and will likely lower your health-related quality of life.
Of course the fact that you actually got biopsies may indicate that you and your treatment team are choosing to be more aggressive in pursuing the disease. You don't mention what data led to the decision to biopsy.
Given the advanced results of your biopsy you would not generally be considered the best candidate for radiation. If you were younger, you might be considered a candidate for the most aggressive treatment--radical prostatectomy, salvage radiation, and hormone therapy. So whatever you and your treatment team choose will likely be a balance between your life expectancy and quality of life versus aggressive treatment of one possible cause of your eventual decline and death.
While this situation might be considered discouraging--after all, your personal life expectancy, similar to all of us, is getting shorter every day, it could also be viewed as liberating. You have the freedom and permission, earned over many years, to choose whatever you want, including skipping your next consult for one more game of golf or pickleball ;-).

Rather than jumping directly to treatment possibilities and decisions, I would hope you have three or four conversations to explore your situation further. E.g., with life partner, closest friends, family (children, grandchildren), spiritual advisor ( if appropriate) These might be preceded by a consult with a medical oncologist specializing in urology.

Explore your own emotions and values through these conversations, and that will arm you for your further meetings with the doctors.

Warning: Attempt at irreverent humor below. Apologies in advance if offensive to anyone.

To treat or not to treat; that is the question.
Or maybe "Are you feeling lucky"?

Summary: I would choose the least invasive treatment, if any. And maximize the length of time that I feel fit and healthy.

And as noted above, there are a number of questions about the history of your diagnosis that probably are relevant.

I am a "surgery guy".
At 72 with Gleason 9, I had RP at a COE and an excellent recovery post op. Very good continence and actually played golf at 6 weeks.
However, others have had less good fortune with side effects from surgery, some long lasting.

Unfortunately for me, I had immediate BCR, resulting in Salvage radiation tx of 4 mos of ADT wrapped around 2 mos of IMRT photon radiation treatment to prostate bed and lymph nodes.

Again, excellent results with first 2 PSAs post tx less than .02 undetectable.

So now at 74, I feel well and hope and pray that my "investment " in treatment pays me back with a number of years before I face a second recurrence and additional treatment decisions. My parents both lived to 95, although statistically that is not the prognosis for me.

And while I would choose surgery again, it has been a HARD year and a half.

My layman thought is that Radiation might be the least invasive tx w/ a minimal amount of immediate side effects (not a guarantee).

And I would want to avoid any ADT, as that would have an immediate and significant impact on your QOL. It messed with my mind, balance and stamina.

So I end where spino began: Quite the conundrum; both medically and personally.

Wishing you the best counsel and guidance from your physicians, and peace with your decisions .

At 74 my UCLA surgeon recommended surgery for my GL 9 aggressive CR PC but he advised that surgery and radiation are equally effective for an initial treatment At 88 I would think that radiation would be a better choice providing that you live close to your radiation facility Good luck You’re doing great!!

Thank you all for the advice given to me. My appointment with Dr Lee is on Tuesday, March 12th. He claims he did 6300 RP's, and I am hoping he wouldn't recommend surgery for my situation and recommends radiation. Then it would be more reassuring if a surgeon recommends radiation!
I am leaning towards Proton therapy in San Diego and reached out to them for an appointment Dr. Rossi.
I will also consult with RO's at UCI, City of Hope and UCLA before I make a final decision.
Any suggestions who is the doctor that does most prostate treatments at any of these centers?

I want to consult with a GU Medical oncologist at the same center where I get radiation treatment. Anyone can recommend a good medical oncologist at UCSD and City of Hope? I am guessing I would choose either proton Therapy in San Diego or Photon therapy at city of Hope Irvine facility.

Given that you have a G9 tumor and you are 88 (regardless of heath) I would be surprised if any urologist recommended surgery over RT.

two things I overlooked initially on my pathology report;
Intraductal carcinoma
Perineural invasion is present
Anyone has any experience treating this condition? Do I need chemo in addition to radiation? Do I need any other scan like PSMA/Pet scan to detect if cancer already spread outside the prostate even though MRI image shows it is contained within the gland?

G9, intraductal prostate carcinoma is considered high grade. I am not a MO but don't believe they would give you chemotherapy. That is reserved for patients with metastatic disease. Your physician would be the one to decide if you need a PSMA PET prior to RT.