At present, focal laser ablation (FLA) as a new PCa local treatment has attracted attention. We aim at comparing the survival outcomes between radiotherapy (RT) and FLA to reveal whether FLA can be used as an alternative to RT for patients with low and intermediate-risk localized PCa.We conducted analyses with data from the SEER database (2004-2015). Propensity score matching and instrumental variate (IV) were used to reduce the influence of bias and unmeasured confounders maximally.In the adjusted multivariate regression, FLA had lower overall survival (OS) benefits (HR = 1.49; 95%CI: 1.18-1.87; p < 0.001). After propensity score matching, RT still had better OS (HR = 1.50; 95%CI: 1.17-1.93; p = 0.001). The outcomes of IV-adjusted analysis showed FLA was significantly inferior to RT in OS (HR = 1.49; 95%CI: 1.18-1.87). In the subgroup analyses, for those with PSA < 4 ng/mL, FLA showed markedly worse OS and cancer-specific mortality (CSM) outcomes (OS HR = 1.89; 95%CI: 1.01-3.53; p = 0.0466 and CSM HR = 4.25; 95%CI: 1.04-17.43; p = 0.044).FLA is a promising focal therapy of PCa. But our research demonstrated RT still had an obvious advantage in survival benefits over FLA. Using FLA as an alternative treatment for RT requires careful consideration by clinicians.