Ultrasound and Multiparametric MRI for Avoiding Prostate Biopsies in Patients with Elevated PSA and Benign Prostatic Enlargement

Benign prostatic enlargement (BPE) often leads to elevated prostate-specific antigen (PSA) levels, complicating the decision of whether to perform a prostate biopsy prior to surgery. This study aimed to evaluate the efficacy of multiparametric magnetic resonance imaging (mpMRI) in safely determining which patients with elevated PSA levels and indications for BPE surgery could avoid unnecessary biopsies. In this prospective study, 145 men, with a median age of 71.11 years and elevated PSA levels (greater than 4 ng/ml, or 2 ng/ml for those on 5-alpha-reductase inhibitors), underwent 1.5 Tesla mpMRI before transrectal ultrasound (TRUS) biopsy. In cases where mpMRI identified focal lesions, additional biopsy samples were collected using a fusion-guided technique. Histopathological results from biopsies served as the standard reference, with clinically significant prostate cancer (PCa) defined as ISUP grade greater than 2. Two scenarios were assessed: the first considered mpMRI PIRADS 1 and 2 as negative, while the second also included PIRADS 3 as negative. The results indicated that, in the first scenario, mpMRI showed a sensitivity of 66.6% and a negative predictive value (NPV) of 87.9% for any PCa, with sensitivity for clinically significant PCa reaching 77.7% and an NPV of 95.6%. In the second scenario, sensitivity for any PCa dropped to 45.4%, yet the NPV remained high at 85.2%. These findings suggest that prostate mpMRI can effectively prevent unnecessary biopsies in patients with elevated PSA and surgical indications due to BPE, given its significant negative predictive value.