New to group, Pre biopsy testing

Posted by corsair @corsair, 1 day ago

I'm new here to this discussion group. I have been following with interest many of the topics here.
I am 67, have had on and off BPH issues since my 40's. For which I chose to do nothing with besides monitor.
Over the past year though things changed after taking antihistamines / antibiotics for a case of pneumonia. My prostate didn't like that and made urinating very difficult. Family Doc prescribes flomax and refers me to a Urology group.
A PSA was run at the time indicating 15.2.
Since going to the Urology group (after a few months of waiting to get in) a number of tests and an MRI have been performed. I've listed them here:

Labs/Imaging
- PSA (04/2025): 15.229
- PSA (08/19/2025): 5.24
- ExoDx (11/24/2025): 72.91
- ISO PSA (04/14/2026): Total PSA 8.3, risk result 8.
- Prostate MRI (09/02/2025): Prostate volume 70cc. 10x4 mm PIRADS 3 lesion in left transitional zone of mid-gland. No extracapsular extension or lymphadenopathy. BPH, mild bladder wall thickening noted.
- CarePath (03/15/2026): Average Qmax 8 mL/sec (obstructed, < 10 mL/sec).

The results seem to be leading down the path to a biopsy. Is this a correct assumption given what is listed here? Or are there other non invasive tests that can be done?

Thanks in advance for your opinions and advise.

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jayhall | @jayhall | 1 day ago

Your PSA of 15 then 8 and the MRI result that found a PIRADS lesion both indicate that a biopsy is needed. So yes a biopsy is the logical next step. One other test is a PSE that is just a blood test. It's more accurate than a standard PSA. If your Urologist doesn't offer it, insist on getting one done.

wheel1 | @wheel1 | 1 day ago

It would seem your ExoDx and your ISOPSA also exceed their threshold numbers so that combined with your PSA and identified PIRADS 3 lesion definitely call for a biopsy. I don’t know trying to add any additional diagnostic tests change any of that. With a identified PIRADS lesion they will probably want to do an MRI fusion guided biopsy to get multiple bites from the lesion then there random grid across the rest of the prostate.

jim18 | @jim18 | 1 day ago

It has been 8 months since the last PSA. If that is not a typo (15 vs 5) what your PSA is and how fast it is rising is unknown. It can go from 15 to 5 if prostate was infected at time of the 15 or it could have been a lab error on either test. Get another PSA to confirm number and rate of increase. With the ExoDx and ISOPSA well into probable cancer likely there is at least low grade (3+3 or 3+4) prostate cancer. Skip the PSE ($1000) and go to a fusion biopsy to make sure the PIRAD3 is sampled. A PIRAD3 is not cancer most of the time but more likely with 2 tests indicating cancer.

mjp0512 | @mjp0512 | 1 day ago

Welcome and sorry you had to find your way here. If the numbers you posted were mine, I would want a biopsy. There is no other way to know if its cancer without one. Best wishes!

charlesprestridge | @charlesprestridge | 23 hours ago

If possible, there is value in having your biopsy (and if necessary another MRI) at a center of excellence or qualified Cancer Center.

These facilities will (usually) be better at MRI’s and fusion biopsies.

You do not have to rush the biopsy, based on your MRI. Taking extra time to find a location where you may want to ultimately receive treatment, would be better (most of the time).

Best wishes

copyman | @copyman | 23 hours ago

Make sure to get a Transperineal fusion guided biopsy. More accurate and less chance of infection if Transrectal is done. Best of luck

charlesprestridge | @charlesprestridge | 22 hours ago

I know transpernial biopsies have some advantages.

However, 1 week ago I had a transrectal biopsy. This was due to Urologist indicating transrectal was more straighforward to complete. The attached video expresses some of this information.

September 2025, I had a transperineal fusion biopsy at a local hospital by local general Urologist. 5 positive cores all gleason 3+3. Only one of (3) targeted cores hit the lesion. The (1) positive-targeted core barely hit lesion. A Random-core had over 90% 3+3. This is a larger 1.5 to 2cm Pirads5 lesion, Doctor was trying to hit.

Last Friday April 2026, repeat Fusion Biopsy. This time it was a transrectal biopsy. This was completed at City of Hope. Surgeon recommended the transrectal. He called me tgis week, indicated 4 of the 5 positive cores were 3+4. The biopsy was repeated because the MRI and PSMA PET indicated lesion likely contained some grade 4.

I do not think the lesion progressed from 3+3 to 3+4 in the past 6 months. I think the 1st biopsy missed sampling the 3+4.

I am not pro transperineal or transrectal. My experience is the transrectal at a good facility with a good Doctor has limited risks of infection. It may have benefits in sampling some lesions/prostates.

The transrectal was very easy. Both biopsies were completed under anastgesia. No pain during procedure. Transperineal caused a little more bleeding and some blood in urine. Transrectal was almost no bleeding and I did not even have blood in urine.