What Is New in Prostate Cancer Diagnosis in 2026: MRI, Transperineal Biopsy and PSMA PET

A raised PSA value is often the first step in the process of diagnosing prostate cancer. In recent years this process has changed considerably: the aim is to reduce unnecessary biopsies and diagnoses of cancers that do not need treatment, without missing significant cancers. The European Association of Urology (EAU) prostate cancer guideline published in March 2026 and the studies presented at the EAU26 congress in London brought new information in this direction. In this article we summarise what has changed for a man with a raised PSA.

What is the first step when PSA is raised?

PSA is specific to the prostate but not to cancer; an enlarged prostate, inflammation or infection can also raise the value. For this reason, the 2026 guideline recommends that men without symptoms and with a PSA between 3 and 10 ng/mL have the test repeated before any further investigations.

The guideline also recommends an individualised, risk-based approach to early detection. It states that in men whose first PSA value is low, the interval between checks can be extended, and that in those with a life expectancy of less than 15 years, efforts at early detection may bring no benefit. We explain how PSA results are interpreted in our article what does a raised PSA mean?

Why is a prostate MRI done before a biopsy?

The guideline gives a strong recommendation for an MRI before biopsy in men suspected of having disease confined to the prostate. Suspicious areas on MRI are scored on a scale from 1 to 5 called PI-RADS. According to the guideline:

• If there is no suspicious area on MRI (PI-RADS 1–2), PSA density is below 0.20 ng/mL/cc and there is no family history of prostate cancer, PSA follow-up without a biopsy can be recommended.
• If the MRI is equivocal (PI-RADS 3) and clinical suspicion is very low (PSA density below 0.10, no family history), the option of follow-up can still be discussed; otherwise, a targeted biopsy is considered.
• If the MRI is suspicious (PI-RADS 4–5), it is recommended that samples are taken from the suspicious area and the tissue around it.

The guideline also stresses that MRI should not be used on its own as the first screening test. MRI is an assessment tool used after PSA and other findings.

What are risk calculators and biomarker tests for?

To help with the biopsy decision in men with a PSA between 3 and 20 ng/mL, the guideline gives MRI a strong recommendation, and a properly calibrated risk calculator or an additional blood or urine biomarker test a weak recommendation. A new table listing risk calculators that have been externally validated five or more times was added to the 2026 edition. These calculators take into account information such as age, PSA, rectal examination, prostate volume and any previous biopsy together.

At the EAU26 congress, preliminary results from two studies in this area were shared:

• PRAISE-U: In five European pilot centres, using PSA density or a risk calculator after PSA was reported to reduce referrals for MRI by 40–60%.
• Organised screening programme in Sweden: In men with a PSA of 2 ng/mL or higher, using a blood test with multiple biomarkers and genetic markers before MRI reduced MRI scans by 67% and biopsies by 40%.

These results relate to screening programmes and are preliminary data that have not been peer reviewed.

Can PSMA PET be used in the diagnosis of prostate cancer?

PSMA PET/CT is an imaging method that marks a protein found in large amounts on prostate cancer cells, and it is mainly used to assess the spread of the disease in patients who have already been diagnosed. The PRIMARY2 study, presented at a special session on the first day of the congress, provided important data on its possible role in diagnosis.

The study, carried out at seven centres in Australia, included 660 men who had not had a biopsy before and whose MRI was equivocal (PI-RADS 3), or of low suspicion but with a high clinical risk (PI-RADS 2). One group went straight to a transperineal biopsy, while the other first had a PSMA PET/CT scan:

• In the PET group, 49% of men were able to avoid a biopsy.
• The detection rate of significant cancer was 12% in the PET group and 16% in the direct biopsy group; the difference stayed within the acceptable margin set in advance in the study.
• Diagnoses of low-risk cancer not needing treatment fell from 32% to 14%.

Points to bear in mind: the results come from a single country, long-term follow-up of the men who did not have a biopsy is ongoing, and PSMA PET is expensive and not available at every centre. At the American Urological Association (AUA) meeting in May 2026, the BIPASS study, which examines the combined use of PSMA PET and MRI before biopsy, was also presented as an ongoing study.

Why is the transperineal route recommended for biopsy?

The 2026 EAU guidelines on prostate cancer and urological infections give a strong recommendation for prostate biopsy to be performed by the transperineal route. The reasons are a lower risk of infection and more rational use of antibiotics. In a systematic review covering 162,577 patients cited in the guideline, the rate of severe infection spreading to the blood (sepsis) is reported as 0.1% with the transperineal route and 0.9% with the transrectal route.

According to the guideline, preventive antibiotics may be omitted for transperineal biopsy in patients without risk factors for infection (weak recommendation). If a transrectal biopsy is to be performed, the recommendations are cleaning the rectum with povidone-iodine, targeted prophylaxis based on a stool or rectal swab culture or prophylaxis with more than one class of antibiotic, and not using fluoroquinolone antibiotics. We describe the steps of the procedure in our article on how a prostate biopsy is done.

What else is new in the 2026 guideline?

• Men aged 45–55: Based on an analysis of a screening study in Germany, the guideline states that in this age group, systematic biopsies remain important in addition to MRI-targeted samples.
• Micro-ultrasound: A new section was added that includes a study comparing biopsy with high-resolution ultrasound against MRI fusion biopsy.
• Risk group table: The EAU risk group table for localised and locally advanced prostate cancer was revised. In the current table, the intermediate-risk group is divided into two subgroups, “favourable” and “unfavourable”; this distinction guides the discussion of active surveillance and treatment options.

What does this mean for a man with a raised PSA?

In practice, the usual path is as follows: PSA is repeated a few weeks later; if the value stays high, an examination, PSA density and, if necessary, a risk calculation are carried out; a prostate MRI is then performed. If a biopsy is needed, the method and route are chosen according to the MRI findings, personal risks and the facilities of the centre. Methods such as PSMA PET may be considered in selected cases. For details, see the prostate cancer page.

When should you see a urologist?

It is advisable to see a urologist if your PSA has been high on repeated measurements, if it has risen markedly compared with your previous values, if prostate cancer was diagnosed in a family member before the age of 60, or if you have noticed a change in your urine flow. Bringing your previous PSA results and, if you have one, your MRI report with you makes the assessment easier.

Op. Dr. Mücahit Kabar sees patients in Bursa (Nilüfer), Turkey, at Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00, +90 444 8 112) and Özel Jimer Hastanesi (weekdays 13:00–17:00, +90 444 45 67). Appointments are booked through the hospitals’ online booking pages or appointment lines. Consultations are held in English or Turkish; the hospitals’ international patient departments can arrange interpreters for other languages. If you are travelling from abroad, you can send your questions, previous PSA results and MRI report by WhatsApp to +90 541 622 54 82 before your visit. See the contact and appointment information for details.

Sources

• EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer 2026 – Full text (PDF)
• EAU Guidelines on Prostate Cancer 2026 – Summary of changes
• EAU Guidelines on Urological Infections 2026 – Full text (PDF)
• Scan that makes prostate cancer cells glow could cut need for biopsies – EAU press release (PRIMARY2)
• PSMA PET-CT Scan Reduces Need for Prostate Cancer Biopsies – The ASCO Post
• Effect of [68Ga]Ga-PSMA-11 PET-CT in the diagnosis of prostate cancer in men with equivocal or clinically high-risk non-suspicious findings on multiparametric MRI (PRIMARY2) – The Lancet Oncology
• Research presented at international urology conference in London shows how far prostate cancer screening has come – EAU press release
• EAU26 Highlights: Day 1 – Uroweb
• AUA 2026: Phase 3 Study of 68Ga-PSMA-11 PET Combined with MRI for the Detection of Prostate Cancer (BIPASS) – UroToday