Context-Dependent Role of Digital Rectal Examination in a Contemporary Prostate Biopsy Cohort: Differential Predictive Value With and Without mpMRI

To quantify the context-dependent contribution of digital rectal examination (DRE) to the prediction of clinically significant prostate cancer (csPCa, ISUP grade group ≥2) in a contemporary biopsy cohort, comparing a non-mpMRI clinical pathway with an mpMRI-informed pathway including PI-RADS. We performed a retrospective analysis of 666 consecutive prostate biopsies at a single academic center (July 2017–December 2024). DRE was performed by urology residents and attending urologists. Two multivariable logistic regression models were constructed: Model A (full cohort, N=612) included age, log-PSA, log-PSAD, prior biopsy, and DRE; Model B (mpMRI subcohort, N=306) additionally included PI-RADS score. Discrimination was assessed using AUC and likelihood ratio tests. Sensitivity analyses evaluated any cancer (ISUP ≥1) and high-grade cancer (ISUP ≥4). csPCa prevalence was 30.7% (202/660), and DRE was suspicious in 52.3% (346/662). In Model A, DRE was independently associated with csPCa (aOR 2.18, 95% CI 1.45–3.28, p<0.001), although the gain in discrimination was modest (ΔAUC=0.009). In Model B, DRE showed borderline significance (aOR 1.88, 95% CI 1.01–3.52, p=0.048) with negligible discrimination gain (ΔAUC=0.002). Sensitivity analyses showed consistent findings. A dose–response gradient was observed: csPCa rates were 19.2% (normal), 31.6% (cT2a), and 58.9% (cT2b–T4) (p-trend <0.0001). DRE was independently associated with csPCa in the absence of mpMRI, but its incremental discriminative contribution was modest and became negligible once PI-RADS was incorporated. These findings support a limited, context-dependent role for DRE in contemporary biopsy pathways.