The utility of PSA density for selection of targeted versus systematic transperineal prostate biopsy: A retrospective...

The objective of this study is to evaluate PSA density (PSAD) as an adjunctive predictor of prostate cancer (PCa) detection on magnetic resonance imaging (MRI)-guided transperineal biopsy and to identify PSAD thresholds across which systematic sampling may be safely omitted.

Data were collected from men who underwent MRI-ultrasound software-assisted fusion transperineal biopsy from July 2023 to August 2025. The cancer detection rate of targeted, systematic and combined strategies was stratified by PSAD. Multivariable logistic regression was used to identify predictors of grade group (GG) ≥ 2 and GG ≥ 3 PCa.

Among 379 men undergoing biopsy, overall GG ≥ 2 detection increased with PSAD: 29.2% (<0.1), 42.7% (0.1-0.1499), 61.2% (0.15-0.1999) and 78.4% (≥0.2). On multivariable analysis, PSAD was associated with higher odds of GG ≥ 2 (OR 2.4, 95% CI 1.73-3.3, p < 0.001) and GG ≥ 3 (OR 2.3, 95% CI 1.65-3.2, p < 0.001) PCa. At PSAD ≥ 0.2, the inclusion of systematic biopsy increased detection of GG 1 cancer by 42.3% but only increased detection of GG ≥ 2 and GG ≥ 3 cancer by 7.2% and 6.2%, respectively. Among 96 men who underwent radical prostatectomy, combined biopsy demonstrated the strongest grade group concordance at prostatectomy (κ = 0.747), though the difference between targeted and combined biopsy narrowed among those with PSAD ≥ 0.2 (κ = 0.628 vs. 0.584).

PSAD is an accessible metric that may guide risk stratification and biopsy strategy selection. A PSAD threshold of 0.2 may identify those in whom systematic sampling increases detection of low-grade disease with limited incremental yield for clinically significant disease.