A Practical Algorithm for Evaluation of Men With persistently Raised PSA: Is the Role of DRE Underestimated?
Affiliation
Krishna Rao Gurugubelli1, Bharat Kumar1, Sachin Bhagwan Dhakare1, Atul Vishwanath Domakuntla1, Arun Kumar SM2, Lal Darsan3, H Krishna Moorthy4*
1DrNB Resident, Department Of Urology, Lourdes Hospital-Postgraduate Institute of Health Sciences and Research, Pachalam, Kochi, Kerala, India
2Consultant Radiologist, Lourdes Hospital-Postgraduate Institute of Health Sciences and Research, Pachalam, Kochi, Kerala, India
3MS (Surg), DNB (Surg), FMAS, Mch (Urology), Consultant Urologist, Department of Urology, Lourdes Hospital-Postgraduate Institute of Health Sciences and Research, Pachalam, Kochi, Kerala, India
4MS(Surg), DNB (Surg), Mch (Urology), DNB (Urology), MNAMS, Senior Consultant & Head of the Department, Department of Urology, Lourdes Hospital-Postgraduate Institute of Health Sciences and Research, Pachalam, Kochi, Kerala, India
Accepted: May 19, 2026 Published: July 16, 2026
Correspondence to: Dr. H. Krishna Moorthy, MS(Surg), DNB (Surg), Mch (Urology), DNB (Urology), MNAMS, Senior Consultant & Head of the Department, Department of Urology, Lourdes Hospital-Postgraduate Institute of Health Sciences and Research, Pachalam, Kochi, Kerala, India. Email: dr.moorthy65@gmail.com
Citation: Gurugubelli KR, Kumar B, Dhakare SB, Domakuntla AV, Arun Kumar SM, Darsan L, Moorthy HK. A Practical Algorithm for Evaluation of Men with Persistently Raised PSA: Is the Role of DRE Underestimated?. American Research Journal of Urology, Vol 8, no. 1, 2026, pp. 1-5.
Copyright: © 2026 Moorthy HK, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background: Symptomatic men with elevated prostate-specific antigen (PSA) pose a diagnostic challenge due to overlap between benign and malignant conditions. A structured, algorithm-based approach integrating clinical examination, imaging, and appropriate biopsy modality may improve diagnostic accuracy while reducing unnecessary procedures.
Objective: To evaluate an algorithm-based diagnostic approach for symptomatic men with elevated PSA, stratified by clinical palpability, and to assess the diagnostic performance of finger-guided transrectal biopsy and multi parametric MRI-directed TRUS (trans rectal ultrasound) cognitive fusion biopsy.
Materials and Methods: This prospective observational study included 78 symptomatic men with persistently elevated PSA of >4ng/ml who underwent prostate biopsy. Patients were stratified based on digital rectal examination (DRE) into clinically palpable and non-palpable prostate groups. Patients with palpable lesions underwent finger-guided transrectal biopsy, while those with non-palpable prostates underwent multiparametric MRI (mpMRI), followed by TRUS-guided cognitive fusion biopsy for PI-RADS ≥ III lesions. Final diagnosis was confirmed by biopsy, TURP histopathology when performed, or serial PSA follow-up when treatment is inconclusive of malignancy.
Results: Among 56 patients with clinically palpable lesions, finger-guided biopsy detected carcinoma prostate in 36 patients, with one false-negative identified on TURP. Sensitivity, specificity, PPV, NPV, and diagnostic accuracy were 97.2%, 100%, 100%, 95%, and 98.2%, respectively. Among 22 patients with clinically non-palpable prostates and PI-RADS ≥ III lesions, TRUS-guided cognitive fusion biopsy detected malignancy in 13 patients, with 100% sensitivity, specificity, and diagnostic accuracy. No statistically significant difference in cancer detection was observed between groups (p = 1.00).
Conclusion: An algorithm-based approach integrating DRE, mpMRI, and tailored biopsy techniques provides excellent diagnostic accuracy in men with persistently elevated PSA. Finger-guided biopsy remains effective in clinically palpable lesions, while mpMRI-directed TRUS biopsy is highly reliable in clinically non-palpable cases.
Keywords: Prostate-Specific Antigen; Prostatic Cancer Diagnostic Algorithm; Digital Rectal Examination; Multiparametric MRI; TRUS-Guided Biopsy.
