Multicenter Study on Integrating Prostate Magnetic Resonance Imaging with Prostate-Specific Antigen Density for Risk-Adapted Biopsy Strategy in a South Korean Cohort

Objective: Combining Prostate Imaging-Reporting and Data System (PI-RADS) with prostate-specific antigen density (PSAD) may improve the detection of clinically significant prostate cancer (csPCa) while reducing unnecessary biopsies. This study aimed to evaluate csPCa detection rates using PI-RADS and PSAD, identify optimal PSAD cutoffs, and assess biopsy strategies to optimize csPCa detection and reduce unnecessary procedures within a South Korean cohort.

Methods: This multicenter retrospective study included 3117 biopsy-naïve patients from 2 tertiary hospitals in South Korea (2020-2025) who underwent magnetic resonance imaging–based transperineal prostate biopsy. Patients were stratified into PI-RADS groups (1-2, 3, 4-5) and PSAD categories (<0.10, 0.10-0.15, 0.15-0.20, and ≥0.20). Receiver-operating characteristic (ROC) curve analyses validated PSAD cut-offs, and biopsy strategies were compared for csPCa detection and biopsy avoidance.

Results: The overall csPCa detection rate was 47.1%. PI-RADS 4-5 patients had high detection rates across all PSAD levels (20.1%-76.5%), while PI-RADS 1-2 and 3 patients with PSAD ≥ 0.15 showed elevated rates (15.2%-16.9% and 25.0%-35.7%, respectively). ROC curve analyses identified optimal PSAD cut-offs of 0.155 (area under the ROC curve (AUC), 0.708) for PI-RADS 1-2 and 0.145 (AUC, 0.749) for PI-RADS 3. The proposed strategy (PI-RADS ≥ 4 or PI-RADS 1-2 or 3 with PSAD ≥ 0.15) outperformed other strategies, avoiding 448 (14.4%) biopsies, missing 28 (1.9%) csPCa cases, and achieving a negative predictive value of 93.8%.

Conclusion: Integrating PI-RADS with PSAD enhances risk stratification for csPCa, maintaining high diagnostic accuracy while reducing unnecessary procedures.

Cite this article as: Lee SJ, Shin DH, Kim HY. Multicenter study on integrating prostate magnetic resonance imaging with prostate-specific antigen density for risk-adapted biopsy strategy in a South Korean cohort. Urol Res Pract. 2026, 52, 0014, doi: 10.5152/tud.2026.26014.