Urologic Section, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy -
Urologic Section, Department of Oncology, AOU G. Martino, Messina, Italy -
Minerva Urol Nephrol. 2024 Oct;76(5):530-535. doi: 10.23736/S2724-6051.24.06118-4.
Voluntary PCa screening frequently results in excessive use of unnecessary diagnostic tests and an increasing risk of detection of indolent PCa and unaffordable costs for the various national health systems. In this scenario, the Italian Society of Urology (Società Italiana di Urologia, SIU) proposes an organized flow chart guiding physicians to improve early diagnosis of significant PCa avoiding unnecessary diagnostic tests and prostate biopsy.
According to available evidence and international guidelines [i.e., European Association of Urology (EAU), American Association of Urology (AUA) and National Comprehensive Cancer Network (NCCN)] on PCa, a Panel of expert urologists selected by Italian Society of Urology (SIU, Società Italiana di Urologia) proposed some indications to develop a stepwise diagnostic pathway based on the diagnostic tests mainly used in the clinical practice. The final document was submitted to six expert urologists for external revision and approval. Moreover, the final document was shared with patient advocacy groups.
In voluntary men and symptomatic patients with elevated PSA value (>3 ng/mL), the Panel strongly discourage the use of antibiotic agents in absence of urinary tract infection confirmed by urine culture. DRE remains a key part of the urologic physical examination helping urologists to correctly interpret PSA elevation and prioritizing the execution of multiparametric Magnetic Resonance Imaging (mpMRI) in presence of suspicious PCa. Men with negative mpMRI and low clinical suspicion of PSA (PSA density < 0.20 ng/mL/cc, negative DRE findings, no family history) can be further monitored. Men with negative mpMRI and a higher risk of PCa (familial history, suspicious DRE, PSAD>0.20 ng/mL/cc or PSA>20 ng/mL) should be considered for systematic prostate biopsy. While PI-RADS 4-5 lesions represent a strong indication for prostate biopsy, PI-RADS 3 lesions should be further stratified according to PSAD values and prostate biopsy performed when PSAD is higher than 0.20. Accreditation, certification, and quality audits of radiologists and centers performing prostatic mpMRI should be strongly considered. The accessibility and/or the waiting list for MRI examinations should be also evaluated in the diagnostic pathway. The panel suggests performing transperineal or transrectal targeted plus systematic biopsies as standard of care.
Scientific societies must support the use of shared diagnostic pathway with the aim to increase the early detection of significant PCa reducing a delayed diagnosis of advanced PCa. Moreover, a shared diagnostic pathway can reduce the incorrect use of antibiotic, the number of unnecessary laboratory and radiologic examinations as well as of prostate biopsies.
前列腺癌的自愿筛查常常导致不必要的诊断性检查过度使用，并增加检测到惰性前列腺癌的风险和各种国家卫生系统难以承受的费用。在这种情况下，意大利泌尿科协会（Società Italiana di Urologia，SIU）提出了一个有组织的流程图，指导医生改进对有意义的前列腺癌的早期诊断，避免不必要的诊断性检查和前列腺活检。
根据现有的证据和国际指南[即欧洲泌尿外科学会（European Association of Urology，EAU）、美国泌尿外科学会（American Association of Urology，AUA）和国家综合癌症网络（National Comprehensive Cancer Network，NCCN）]关于前列腺癌的建议，意大利泌尿科协会（SIU）的一个专家组选择了一些适应证，根据主要在临床实践中使用的诊断性检查制定了一个逐步的诊断途径。最终文件提交给六位专家泌尿科医生进行外部审查和批准。此外，最终文件与患者权益团体共享。
在自愿接受检查的男性和 PSA 值升高（>3ng/mL）的有症状患者中，专家组强烈反对在未通过尿液培养证实存在尿路感染的情况下使用抗生素。直肠指检仍然是泌尿科体检的关键部分，有助于泌尿科医生正确解读 PSA 升高，并在可疑前列腺癌存在时优先进行多参数磁共振成像（mpMRI）。对于 mpMRI 阴性且 PSA 升高临床可能性较低的患者（PSA 密度<0.20ng/mL/cc，直肠指检阴性发现，无家族史）可进一步监测。对于 mpMRI 阴性且前列腺癌风险较高的患者（家族史、可疑直肠指检、PSAD>0.20ng/mL/cc 或 PSA>20ng/mL），应考虑进行系统的前列腺活检。当 PI-RADS 4-5 病变代表强烈的前列腺活检指征时，PI-RADS 3 病变应根据 PSAD 值进一步分层，并在 PSAD 高于 0.20 时进行前列腺活检。应强烈考虑对进行前列腺 mpMRI 的放射科医生和中心进行认证、认证和质量审核。在诊断途径中还应评估前列腺 mpMRI 的可及性和/或等待时间。专家组建议作为标准护理，进行经会阴或经直肠靶向加系统活检。
科学协会必须支持使用共享的诊断途径，以提高对有意义的前列腺癌的早期发现，减少晚期前列腺癌的延迟诊断。此外，共享的诊断途径可以减少抗生素的不当使用、不必要的实验室和影像学检查以及前列腺活检的数量。
