One of the commonest scenario in clinical practice :

Age above 70 years 
O/e: BEP 
Do we need to do PSA in all? 
Do we need to do PSA prior to TURP if patient in need of surgical intervention? 
Why and why not? 


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  • Lalit Shah
    Lalit Shah
    01 Feb 2020 02:39:20 PM

    70 years

    Clinically BPH
    If I am patient, with my knowledge and experience of Urology, I would not get PSA done!!

  • Dr Anil Elhence
    Dr Anil Elhence
    01 Feb 2020 04:09:31 PM

    Age will need to be seen in conjunction with the patient's health status, in other words his life expectancy. If patient fit, I would ask for PSA and do subsequent imaging if PSA raised
    Oppurtunistic screening in those presenting to an Urology OPD is justified in that an option for curative procedure may be available, this is true specially for those fit enough to undergo the work up and live long enough to benefit from intervention.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    01 Feb 2020 05:25:15 PM

    Dear Anil,

    Agree with most of your thoughts. 
    But you have not mentioned possible morbidities related to radical procedures 
    We have to think about possible benifits against morbidities,  anxiety and costs related to almost indolent prostatic carcinoma in this provided scenario...

  • Nitesh Jain
    Nitesh Jain
    01 Feb 2020 05:41:57 PM

    You need to do a test if you are planning to intervene or test result will change your management 

    Finding a significant CaP in a elderly patient with normal DRE is unlikely , there are ample literatures available on that 

    Finally age is just no, but do a test if you feel the ultimate result will change the management as biopsing this elederly gentleman you will end up getting indolent cancer which will add to anxiety and over treatment without any great advantage

  • Rahul Kapoor
    Rahul Kapoor
    02 Feb 2020 04:06:22 PM

    For a 70 years ... yes i usually do. But if we increase the age ...lets say 80. Then probably no. DRE is important. Which will help in deciding the treatment plan. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    02 Feb 2020 07:19:42 PM

    Dear Rahul,

    Can you please explain why you will do PSA in posted scenario?
    >70 years
    DRE: Suggestive of BEP


  • Rahul Kapoor
    Rahul Kapoor
    03 Feb 2020 05:25:27 PM

    For patient in 70, detecting a malignancy by S.PSA (APPROX. 16%) will be helpful and change the management. 

    But elderly patient with low overall life expectancy and normal DRE, it wont make change in planned treatment in most of the cases

  • Dr. Anil Takvani
    Dr. Anil Takvani
    03 Feb 2020 07:43:11 PM

    Dear Rahul,

    So what is conclusion?
    Shall we practice routine PSA testing in posted scenario?

  • Ankit Fusakele
    Ankit Fusakele
    05 Feb 2020 08:06:38 AM

    I take it other way...

    70 year if you do TURP without doing PSA, and you missed a malignancy ( DRE is always not conclusive), patient is back with advance disease with in few months.

    What is harm doing PSA, if it is raised do a biopsy.because treatment of cancer will be altogether different from BPH.

    Please do not mix concept of mass screeing of PSA and opportunistic screening

  • Dr. Anil Takvani
    Dr. Anil Takvani
    05 Feb 2020 11:11:52 AM

    Thanks for your comments...
    "70 year if you do TURP without doing PSA, and you missed a malignancy ( DRE is always not conclusive), patient is back with advance disease with in few months." Dr. Ankit Fusakele
    Why patient will be back with advance disease?

    "What is harm doing PSA, if it is raised do a biopsy.because treatment of cancer will be altogether different from BPH." Dr. Ankit
    Is it not possible you are lending up with biopsies/radical procedures of possibly indolent Ca. Prostate?
    Which can add morbid complications, costs and anxiety...

  • Amrith Raj Rao
    Amrith Raj Rao
    12 Feb 2020 03:45:09 PM

    One must understanding what is PSA screening! 

    PSA screening DOES NOT mean that one off PSA test. PSA screening means an annual PSA test in every man above the age of 40/50 depending on the country they live in etc. One should NOT confuse one off PSA test to PSA screening. 

    Again, one must NOT forget the findings of MTOPS and REDUCE trial. PSA was found to be an independent predictor for BPH progression and therefore a very reliable indicator as well. Therefore, in a patient with suspected BPH, PSA can be performed! ;-) 

    We are trying to ape the West without understanding what their system is and why they introduce such restrictions on PSA screening. 

    In the UK, one can still offer PSA testing as long as the patient is counselled regarding the same. 

    Warm Regards

  • Dr. Anil Takvani
    Dr. Anil Takvani
    13 Feb 2020 09:31:36 AM

    Thanks Amrith.

    Yesterday I show patient of 75 years age. LUTS. Major symptoms are obstructive. USG: 48 gram prostate with 50cc PVR. 
    P/r: grade two prostate, smooth surface, soft to firm consistency and non tender.
    No UTI. 
    PSA was done at some other center. Value: 6.34ng/mL
    What next you will do? and why?

  • Dr m s ranganath
    Dr m s ranganath
    14 Feb 2020 05:40:56 PM

    PSA in a 70 yr old man to be done if there are specific reasons of a strong family history and DRE is suggestive. Otherwise a rise PSA especially in the grey zone will lead to an unnecessary biopsy

  • Tanuj Paul Bhatia
    Tanuj Paul Bhatia
    20 Feb 2020 11:17:50 PM

    Generally I do PSA for patients <75 yrs with LUTS , but I inform them the purpose and not to Panic if it is found to be raised. In most patients planned for intervention I generally do a PSA as it might change the plan of treatment and also it serves as a marker of good resection or enucleation (when repeated post operatively). 

    Also in very large prostates (most of my HoLEPs), its not possible to palpate the gland completely so I do a PSA preoperatively irrespective of age.

  • Prabir Basu
    Prabir Basu
    22 Feb 2020 08:20:21 AM

    I do PSA in all patients posted for surgery. Those with raised PSA , I refrain from doing Holep . I admit I am not an expert in doing Holep and often tend to loose my planes😟😟. If contemplating open I always advise a biopsy with raised PSA. For TURP with an incidental pre-op raised PSA , I advise a concomitant transrectal biopsy at the same sitting if the patient is not young and fit to that extent that he will be benefited with formal workup for raised PSA. 

  • Venugopal P
    Venugopal P
    25 Feb 2020 10:04:25 AM

    Dear All,

    The controversy on PSA Screening for P Ca will probably never end. I am providing a Podcast which will explain the current position P Ca Screening. This podcast is of 25 duration.

    I am providing a discussion we had in 2010 (when we were in Uroeducation) by many Indian stalwarts on a topic ‘P Ca Screening – To Do or Not to Do’. Though we did not come to any specific Conclusion, it aired the views of many. Though 2010 appear a long time ago and the opinion of these stalwarts could have changed from that time, it is still worth knowing the multitude of views expressed. (PDF provided).

    AUA has stated that a PSA over 2.5ng/mL merits investigating for P Ca while EAU has mentioned 3ng/mL as the upper cutoff limits. In India we still follow 4ng/mL as the cutoff level. It is possible that some in India has changed over to lower cutoff level. The main aim world over is geared towards how to reduce unnecessary Prostate biopsies in the Gray Zone (4 to 10ng/mL)

    The incidence of P Ca is considerably lower in India (Orientals) when compared to Caucasians. It is interesting that the incidence of P Ca in many native countries from where the African Americans migrated is low but when migrated there incidence is the largest in USA. Asians who live in USA have a higher incidence of P Ca when compared to Asians in Asia but the incidence is much lower when compared to Caucasians.

    Do we need to advice Prostate Biopsies in all who have a value of PSA over 4ng/mL. It is well known that many patients in India have a higher PSA value but are not having P Ca. The same is found among Orientals as well.

    I would direct you to an article from Sujata et al (2018) in which they state that ‘PSA value 9.7ng/ml should be considered as the cut point above which prostatic biopsy should be done to avoid unnecessary biopsies. Unless accompanied by abnormal DRE finding at PSA range 4–10 ng/ml, morbidity of prostatic biopsy procedure can be avoided using this cut point’.;year=2018;volume=10;issue=1;spage=65;epage=70;aulast=Patwardhan (PDF available)

    There was a similar article from Suryaprakash (I am not able to lay my hands on it now) in which he has stated that the cutoff value for initiating biopsy was 11ng/mL. But Shalini Agnihotri, Anil Mandhani (2014) mention 5.4ng/mL as the cutoff value.;year=2014;volume=139;issue=6;spage=851;epage=856;aulast=Agnihotri (PDF available)

    Rong Na, Qiang* et al (2013) in their study showed that ‘at the 90%sensitivity, the specificity for predicting P Ca in the men #60 years old was 68% with the cutoff value of 14.0ng/mL’.

    Today mpMRI has become the most favoured investigation for detection and staging of P Ca. Recent studies have shown that even though it provides a high yield for Clinically Significant P Ca, it still fails to provide the needed diagnosis in fair number of cases. PIRADS with measuring PSA density is said to provide more information as regards aggressiveness of a lesion in PIRADS 3.

    Studies have indicated that combined use of PHI < 24.4 and PI-RADS ≤ 3 could have avoided 24% of active surveillance biopsies at the cost of missing only 4% of grade reclassification.

    Many Genetic Testing are on the anvil suggesting that they could be of help in the decision making as to the need for Biopsy. A Genetic Risk Score (GRS), including high risk genetic markers and SNPs, has been proposed to help with risk stratification of prostate cancer especially in families; but this type of testing is not yet ready for individual patient diagnostics.

    Hayley Pye et al from University College London, presented their study during GU Cancer Symposium on Feb 18th 2020 on the utility of the Risk score utilizing Proclarix Risk Score. This blood-based test can identify men with elevated prostate-specific antigen (PSA) levels who can safely avoid an upfront multi-parametric magnetic resonance imaging (mpMRI) or men who could avoid biopsy when mpMRI was intermediate. This, easy to use blood test that measures Thrombospondin 1 and Cathepsin D. The test can be done with the same sample as the PSA test. The use of Proclarix could potentially allow 38% of men to avoid undergoing an mpMRI and without missing any clinically significant cancer.

    When USPSTF introduced Grade ‘D’ Recommendation for P Ca screening with PSA, bugles of war sounded all over the globe which forced USPSTF to change the recommendation form ‘D’ to ‘C’. But they maintain that it may be unnecessary to screen after the age of 70. But this has been disputed by stating that many over 70 are still active with minimal comorbidities and why they should be excluded.

    The debate will never end.

    With warm regards,



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