Risk stratification for repeat prostate biopsy: PI-RADS 3 lesions and the differential role of PSA density.

PURPOSE: PI-RADS 3 lesions represent a diagnostic challenge in repeat prostate biopsy. We investigated whether PI-RADS 3 independently predicts negative biopsy outcomes and how PSA density (PSAD) modifies cancer detection across PI-RADS categories.

MATERIALS AND

METHODS

We retrospectively analyzed 684 patients who underwent repeat MRI-guided prostate biopsy between 2015 and 2022. PI-RADS scores, clinicopathologic variables, biopsy Gleason Scores, and radical prostatectomy findings were assessed. Univariate and multivariate logistic regression identified predictors of positive biopsy. Subgroup analysis examined detection rates stratified by PI-RADS and PSAD.

RESULTS

Overall, 238 patients (34.8 %) had positive biopsies. PI-RADS 3 was identified in 210 patients (30.7 %) and PI-RADS 4-5 in 274 (40.1 %). Cancer detection differed significantly: 19.0 % for PI-RADS 3 versus 51.8 % for PI-RADS 4-5 (P < 0.001). Multivariate analysis confirmed PI-RADS 3 as an independent predictor of negative biopsy (OR 0.582, 95 % CI 0.364-0.929, P = 0.023), while PI-RADS 4-5 predicted positive biopsy (OR 2.438, P < 0.001). PSAD strongly stratified risk in PI-RADS 4-5 lesions (33.8 % vs 62.4 %, P < 0.001) but showed minimal effect in PI-RADS 3 lesions (16.2 % vs 20.7 %, P = 0.564).

CONCLUSION

PI-RADS 3 lesions independently predict negative biopsy in repeat MRI-guided prostate biopsy. PSAD demonstrates differential predictive utility across PI-RADS categories. Risk-stratified management incorporating imaging and clinical biomarkers may optimize decision-making while minimizing unnecessary procedures.