{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T16:58:49Z","timestamp":1785257929926,"version":"3.55.0"},"reference-count":35,"publisher":"S. Karger AG","license":[{"start":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T00:00:00Z","timestamp":1780531200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/karger.com\/pages\/terms-and-conditions"},{"start":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T00:00:00Z","timestamp":1780531200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/karger.com\/pages\/terms-and-conditions"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Urol Int"],"abstract":"<jats:p>Introduction: Transition zone PSA density (TZ-PSAD) was proposed to improve prostate cancer detection by normalizing PSA to the compartment most affected by benign prostatic hyperplasia (BPH). If valid, TZ-PSAD should provide the greatest benefit in large prostates where BPH predominates. We tested this assumption across prostate volume categories in the largest MRI-based cohort reported to date. Materials and Methods: We analyzed 3,958 consecutive patients who underwent multiparametric MRI with manual zonal segmentation and combined MRI-guided targeted plus systematic transperineal biopsy (March 2010\u2013June 2025). Diagnostic accuracy of TZ-PSAD versus whole-gland PSAD was compared using receiver operating characteristic analysis with DeLong testing. Volume-stratified subgroup analysis (&lt;30 mL, 30\u201350 mL, and &gt;50 mL) assessed performance consistency. Clinical utility was evaluated by decision curve analysis (DCA). Results: Of 3,958 patients, 1,629 (41.2%) had clinically significant prostate cancer (International Society of Urological Pathology grade group: \u22652). TZ-PSAD achieved marginally superior area under the curve (AUC) (0.768 vs. 0.758, p &lt; 0.001; \u0394AUC 0.010). Volume-stratified analysis revealed inconsistent performance: TZ-PSAD was inferior in small prostates (&lt;30 mL: \u0394AUC \u22120.017, p = 0.015), modestly beneficial at intermediate volumes (30\u201350 mL: \u0394AUC +0.013, p = 0.026), and nonsignificant in large glands (&gt;50 mL: \u0394AUC +0.006, p = 0.462). DCA confirmed fewer than 1 additional cancer detected per 1,000 patients at clinically relevant thresholds. Limitations include the retrospective single-center design, absence of PI-RADS-stratified analysis, and incomplete capture of 5-alpha reductase inhibitor exposure. Conclusion: TZ-PSAD fails to outperform whole-gland PSAD in prostates &gt;50 mL, where its theoretical rationale is strongest. The additional complexity of zonal segmentation is not justified for routine clinical use.<\/jats:p>","DOI":"10.1159\/000552900","type":"journal-article","created":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T16:00:43Z","timestamp":1780588843000},"page":"1-9","source":"Crossref","is-referenced-by-count":0,"title":["Transition Zone PSA Density Does Not Improve Detection of Clinically Significant Prostate Cancer over Whole-Gland PSA Density: A Volume-Stratified Analysis in 3,958 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