PURPOSE: Utility of prostate-specific antigen density (PSAd) for risk-stratification to avoid unnecessary biopsy remains unclear due to the lack of standardization of prostate volume estimation. We evaluated the impact of ellipsoidal formula using multiparametric magnetic resonance (MRI) and semi-automated segmentation using tridimensional ultrasound (3D-US) on prostate volume and PSAd estimations as well as the distribution of patients in a risk-adapted table of clinically significant prostate cancer (csPCa). METHODS: In a prospectively maintained database of 4841 patients who underwent MRI-targeted and systematic biopsies, 971 met inclusions criteria. Correlation of volume estimation was assessed by Kendall's correlation coefficient and graphically represented by scatter and Bland-Altman plots. Distribution of csPCa was presented using the Schoots risk-adapted table based on PSAd and PI-RADS score. The model was evaluated using discrimination, calibration plots and decision curve analysis (DCA). RESULTS: Median prostate volume estimation using 3D-US was higher compared to MRI (49cc[IQR 37-68] vs 47cc[IQR 35-66], p < 0.001). Significant correlation between imaging modalities was observed (τ = 0.73[CI 0.7-0.75], p < 0.001). Bland-Altman plot emphasizes the differences in prostate volume estimation. Using the Schoots risk-adapted table, a high risk of csPCa was observed in PI-RADS 2 combined with high PSAd, and in all PI-RADS 4-5. The risk of csPCa was proportional to the PSAd for PI-RADS 3 patients. Good accuracy (AUC of 0.69 and 0.68 using 3D-US and MRI, respectively), adequate calibration and a higher net benefit when using 3D-US for probability thresholds above 25% on DCA. CONCLUSIONS: Prostate volume estimation with semi-automated segmentation using 3D-US should be preferred to the ellipsoidal formula (MRI) when evaluating PSAd and the risk of csPCa.

Departement of Urology Hôpital Cochin Paris France

Department of Radiology Jules Bordet Institute Erasme Hospital Hôpital Universitaire de Bruxelles Université Libre de Bruxelles Brussels Belgium

Department of Urology Centre Hospitalier Universitaire de Reims Reims France

Department of Urology Città Della Salute E Della Scienza Di Torino University of Turin Turin Italy

Department of Urology Clinique Saint Augustin Bordeaux France

Department of Urology Cliniques de L'Europe Saint Elisabeth Brussels Belgium

Department of Urology Grenoble Alpes University Hospital Université Grenoble Alpes CNRS Grenoble INP TIMC Grenoble France

Department of Urology Hôpital Cavale Blanche CHRU Brest Brest France

Department of Urology Hôpital Européen Georges Pompidou Université de Paris U1151 Inserm Institut Necker Enfants Malades Paris France

Department of Urology Hôpitaux Universitaires de Genève Geneva Switzerland

Department of Urology IRCCS Regina Elena National Cancer Institute Rome Italy

Department of Urology Jules Bordet Institute Erasme Hospital Hôpital Universitaire de Bruxelles Université Libre de Bruxelles Brussels Belgium

Department of Urology La Croix du Sud Hospital Quint Fonsegrives France

Department of Urology Private Medical Center Klinika Wisniowa Zielona Góra Poland

Department of Urology University Hospital Ostrava Ostrava Czech Republic

Department of Urology Vivantes Klinikum Am Urban Berlin Deutschland

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