Background: Prostate cancer is the most prevalent malignancy among men in the United States. However, only a limited number of studies have explored the impact of rural-urban disparities in survival among prostate cancer patients with long-term follow-up. In order to investigate disparities in prostate cancer survival, we assess prostate cancer mortality and prognostic factors based on rural-urban residence. Methods: A cohort of 18,134 cancer patients with prostate adenocarcinomas diagnosed between 2004 and 2017 was identified. Residential location information at the time of cancer diagnosis was used to stratify on rural-urban residence. All-cause death and prostate cancer-cause death risks were estimated using Cox proportional hazard regression models. Results: Among prostate cancer patients, 15.1% resided in rural counties in Utah. Patients living in rural counties were different in demographic and clinical characteristics compared to their urban counterparts. An association was observed between rural residence and elevated risks of all-cause mortality (HR=1.19, 99%CI=1.10-1.29) and prostate cancer-specific mortality (HR=1.21, 99%CI=1.03-1.43). Elevated risks of both all-cause and prostate cancer-specific mortality were associated to factors such as unhealthy BMI, comorbidity index ≥1, family history of cancer or prostate cancer, single marital status, low income, low socioeconomic status, government insurance, earlier year of diagnosis, advanced prostate cancer stage, and extensive cancer treatment. Furthermore, the observed disparities in demographic and clinical profiles appeared to contribute to the disparities in all-cause and prostate cancer-specific mortality risks between rural and urban prostate cancer patients. Conclusions: Rural residence exhibited a significant association with the risk of prostate cancer-related and all-cause mortality. Patients residing in rural areas demonstrated distinct factors influencing mortality risks, encompassing both demographic and clinical aspects. These findings underscore the imperative for targeted interventions aimed at mitigating the rural-urban disparities in prostate cancer outcomes.