Artificial Intelligence to Personalize Prostate Cancer Treatment (the HypoElect Trial)

Inclusion Criteria: * Histologically confirmed adenocarcinoma of the prostate (histological confirmation can be based on tissue taken at any time, but a re-biopsy should be considered if the biopsy is more than 12 months old) * Primary PCa (in PSMA-PET imaging and multiparametric magnetic resonance imaging (mpMRI) * High- or very high-risk according to NCCNv1.2023 criteria * Signed written informed consent for this study * Age \>18 years * Previously conducted PSMA-PET/CT, mpMRI or PSMA-PET/MR * MMAI high-risk * ECOG Performance score 0 or 1 * IPSS Score ≤15 Exclusion Criteria: * Prior radiotherapy to the prostate or pelvis * Prior radical prostatectomy * Prior focal therapy approaches to the prostate * Evidence of pelvic nodal disease (cN+) in mpMRI and/or PSMA-PET/CT * Evidence of distant metastatic disease (cM+) in mpMRI and/or PSMA-PET/CT * Time gap between the beginning of any systemic therapyADT and conduction of PSMA-PET scans is \>2 months * Evidence of cT4 disease in mpMRI and/or PSMA-PET/CT * PSA \>50 ng/ml prior to starting of systemic therapy * Expected patient survival \<5 years * Bilateral hip prostheses or any other implants/hardware that would introduce substantial CT artifacts * Contraindication to undergo a MRI scan * Contraindication to undergo HDR brachytherapy (brachytherapy not feasible due to large prostate volume, prostate anatomy, tumor in distant seminal vesicles and/or unfit for anesthesia) * Prostate surgery (TURP or HOLEP) with a significant tissue cavity or prostate surgery (TURP or HOLEP) within the last 6 months prior to randomization * Medical conditions likely to make radiotherapy inadvisable e.g. acute inflammatory bowel disease, hemiplegia or paraplegia * Previous malignancy within the last 2 years (except basal cell carcinoma or squamous cell carcinoma of the skin), or if previous malignancy is expected to significantly compromise 5 year survival * Any other contraindication to external beam radiotherapy (EBRT) to the pelvis * Participation in any other interventional clinical trial within the last 30 days before the start of this trial * Simultaneous participation in other interventional trials which could interfere with this trial; simultaneous participation in registry and diagnostic trials is allowed * Patient without legal capacity who is unable to understand the nature, significance and consequences of the trial * Known or persistent abuse of medication, drugs or alcohol