Prostate cancer is a leading malignancy among men globally. Multiparametric MRI (mpMRI) has improved detection of clinically significant prostate cancer (csPCa), with Prostate Imaging–Reporting and Data System (PIRADS) offering standardized risk assessment. PIRADS 3 lesions, however, remain indeterminate, complicating biopsy decisions—especially in resource-limited settings. This study evaluates cancer detection rates and PSA density (PSAD) correlation in patients with isolated PIRADS 3 lesions undergoing transperineal biopsy at a tertiary centre in Sarawak, Malaysia.

A retrospective review was conducted on 26 patients with isolated PIRADS 3 lesions who underwent transperineal prostate biopsies from 2023 to 2025 at a tertiary centre in Sarawak, Malaysia. PIRADS 4 and 5 lesions were excluded. Biopsy techniques included Biobot robotic-assisted (n=5), Precision Point (n=17), and freehand coaxial transperineal approaches (n=4). PSA levels, MRI-derived prostate volume, and PSAD were analyzed. Histopathological findings were assessed for malignancy. Clinically significant prostate cancer (csPCa) was defined as Gleason score ≥7.

Out of 26 patients, 5 (19.2%) were diagnosed with prostate adenocarcinoma. However, only 1 patient (3.8%) had csPCa (Gleason 3+4, ISUP Grade Group 2), detected via targeted biopsy. The remaining 4 cancer cases were Gleason 6 (ISUP Grade Group 1). PSA density among cancer-positive patients ranged from 0.06 to 0.25, and the patient with csPCa had a PSAD of 0.10. No complications were reported post-biopsy.

This single-centre experience highlights the relatively low prevalence of clinically significant prostate cancer among patients with PIRADS 3 lesions. While 19.2% had histologically confirmed cancer, only a small fraction (3.8%) had csPCa, raising concerns about overdiagnosis. PSA density alone did not consistently predict malignancy or cancer significance. In resource-limited settings, a more targeted approach, reserving biopsy for PIRADS 4 and higher lesions, may optimize cancer detection while minimizing unnecessary procedures. Larger multicentre studies are needed to guide context-specific prostate cancer strategies.