In the Era of mpMRI and PSMA PET/CT: Does Digital Rectal Examination Still Matter?

Area of Science:

• Urology
• Radiology
• Oncology

Background:

• Digital rectal examination (DRE), a traditional prostate cancer (PCa) diagnostic tool, is increasingly sidelined by advanced imaging like multiparametric MRI (mpMRI) and 68Ga-PSMA PET/CT.
• The clinical utility of DRE in the era of modern imaging for PCa diagnosis and staging is uncertain.
• This study reassesses the diagnostic value of DRE in conjunction with contemporary imaging modalities.

Purpose of the Study:

• To evaluate the diagnostic performance of DRE in prostate cancer (PCa) detection and staging.
• To determine the correlation between DRE findings and results from mpMRI and PSMA PET/CT.
• To assess the role of DRE as an adjunctive tool alongside advanced imaging in PCa management.

Main Methods:

• Retrospective analysis of 164 prostate adenocarcinoma patients undergoing transrectal ultrasound-guided biopsy.
• DRE performed prior to biopsy; 151 patients had mpMRI (PI-RADS v2.1 scoring) and 62 had PSMA PET/CT (SUVmax recorded).
• Multivariate statistics and ROC analyses examined relationships between DRE, imaging, biopsy, and pathological staging (post-radical prostatectomy in 156 patients).

Main Results:

• Suspicious DRE findings (n=64) were significantly associated with higher PI-RADS scores, larger lesion size, elevated SUVmax, and clinically significant PCa (p < 0.001).
• Each PI-RADS score increase correlated with a twofold rise in positive DRE likelihood; ROC analysis identified thresholds for DRE positivity (lesion size 13.5 mm, SUVmax 15.1).
• Suspicious DRE strongly correlated with advanced pathological stage (≥ pT3) (p < 0.001).

Conclusions:

• Digital rectal examination (DRE) remains a valuable adjunct for identifying high-risk and advanced prostate cancer (PCa).
• Integrating DRE findings with mpMRI and PSMA PET/CT provides crucial additional clinical insight for risk stratification.
• DRE continues to play a relevant role in the modern prostate cancer diagnostic workflow, particularly for risk assessment rather than initial screening.