In patients with high-volume, clinically localized, intermediate-risk prostate cancer who are sexually active, preoperative surgical planning is critical. There is an increasing dilemma in deciding whether to undertake a nerve-sparing procedure during radical prostatectomy, or to sacrifice one or both neurovascular bundles, which affects functional outcomes. This case describes such a situation and explains how preoperative information, imaging and histopathology techniques, and careful patient counselling can help surgical management to optimize oncological and functional outcomes in these patients.