Episode # 325 • 25 Aug 2026
Navigating the PSA Maze in Urology
Is an elevated prostate-specific antigen (PSA) the beginning or the end of the prostate cancer workup? On this episode of BackTable Urology, Dr. Ruchika Talwar interviews Dr. Tarik Benidir to explore the “PSA problem,” explaining why PSA is biologically useful but clinically imprecise, often leading to false positives, unnecessary biopsies, and detection of indolent disease. They discuss a rational, patient-centered approach to elevated PSA, including when to repeat the test, how to interpret results in the context of age, race, family history, and prostate size, and the use of PSA density and age-adjusted norms instead of rigid cutoffs.
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Timestamps
00:00 - Introduction
04:03 - Why PSA Can Be Misleading
06:43 - Approach to Elevated PSA and Initial Workup
09:51 - MRI, PSA Density, and Biomarker Testing
14:31 - Guidelines, Diagnostics, and When to Biopsy
20:16 - Comparing 4K, IsoPSA, and Other Biomarkers
25:23 - Choosing Between Transperineal and Transrectal Biopsy
28:42 - Management Considerations for Elderly and Comorbid Patients
33:09 - Active Surveillance, Recurrence, and Long-Term Monitoring
40:47 - Key Takeaways and Closing Remarks
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More about this episode
The conversation highlights the role of reflex biomarkers, MRI scans, and selective biopsy strategies to reduce unnecessary procedures and focus on identifying clinically significant cancers. Dr. Benidir explains how to weigh MRI results, when to use biomarkers, and how to approach decisions in elderly or comorbid patients. They also discuss new biopsy modalities, active surveillance, and future directions for optimizing PSA-based screening and management.
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