Prostate Biopsy Results in the PSA Gray Zone: A Five-Year Retrospective Study

Our aim was to analyze and compare the diagnostic efficacy of systematic and targeted + systematic prostate biopsies in patients with prostate-specific antigen (PSA) levels of 4–10 ng/mL. A retrospective study was conducted at University Hospital Centre Zagreb by analyzing biopsy data from 2018 to 2023. A total of 2,466 patients met the inclusion criteria, undergoing either a systematic (n = 1,900) or a combined targeted + systematic biopsy (n = 566). Targeted biopsies were performed for patients with a Prostate Imaging-Reporting and Data System (PIRADS) score ≥ 3 on multiparametric magnetic resonance imaging (mpMRI). Cancer detection rates and Gleason score (GS) distributions were evaluated. Prostate cancer (PC) was diagnosed in 41% of the study cohort. The detection rate was higher in the targeted + systematic biopsy group (54.7%) than in the systematic biopsy group (38.2%). Among biopsy-naïve patients, targeted + systematic biopsy yielded a detection rate of 72.7%, significantly higher than systematic biopsy alone (42.1%). Clinically significant PC (ISUP ≥ 2) was detected in 35.2% of all cases, with targeted biopsies identifying a higher proportion of clinically significant tumors. Operator bias was observed, as systematic cores in targeted biopsy patients often contained malignant cells. The combination of targeted and systematic biopsies demonstrated the highest detection rate of clinically significant prostate cancer, particularly in biopsy- naïve patients. Given the increasing use of mpMRI, this approach should be considered the method of choice for patients with elevated PSA levels. Future studies should assess the financial feasibility of widespread mpMRI implementation in prostate cancer diagnostics.