A Practical Algorithm for Evaluation of Men With persistently Raised PSA: Is the Role of DRE Underestimated?
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.
