The significance of prostate-specific antigen density and free prostate-specific antigen density in the early detection of prostate cancer in individuals experiencing acute urinary retention

Qi Wang^1,2,3,4,5, Jiayan Xin^3,4,5,6, Minghao Zhang^2,3,4,5, Yong Wang^1,*
1 Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
2 Department of Urology, Central Hospital, Tianjin University/Tianjin Third Central Hospital, Tianjin, China
3 Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
4 Artificial Cell Engineering Technology Research Center, Tianjin, China
5 Tianjin Institute of Geriatrics, Tianjin Third Central Hospital Branch, Tianjin, China
6 Department of Cardiology, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, China
* Corresponding Author: Yong Wang. Email: email
(This article belongs to the Special Issue: Advancing Early Detection of Prostate Cancer: Innovations, Challenges, and Future Directions)

Canadian Journal of Urology https://doi.org/10.32604/cju.2026.080510

Received 13 February 2026; Accepted 12 June 2026; Published online 24 July 2026

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Abstract

Backgrounds: Early detection of prostate cancer (PCa) in patients with acute urinary retention (AUR) is complicated by transient, non-malignant elevations of prostate-specific antigen (PSA). Density-based biomarkers such as PSAD and fPSAD may help overcome this limitation. This study aims to assess the diagnostic significance of prostate-specific antigen density (PSAD) and free prostate-specific antigen density (fPSAD) in the early diagnosis of prostate cancer (PCa) among patients with acute urinary retention (AUR). Methods: The clinical data of 1343 patients with AUR were retrospectively analyzed. The differences in the indexes between the PCa group and the benign prostatic hyperplasia (BPH) group were compared. The performance of PSAD and fPSAD for detecting overall PCa and csPCa was analyzed. Diagnostic value was assessed using multivariate Logistic regression, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA). Results: Of the 1343 patients, 647 (48.2%) were diagnosed with prostate cancer (PCa), of whom 512 (79.1%) had clinically significant PCa (csPCa). Both PSAD and fPSAD were independent predictors of PCa and csPCa. For overall PCa detection, the AUC of PSAD was 0.795 and that of fPSAD was 0.776, both significantly higher than the AUC of total PSA alone (0.682, p < 0.01). Subgroup analysis indicated that within the range of 4–10 ng/mL, fPSAD demonstrated better discriminatory ability (AUC = 0.701) compared to PSAD (0.625). In the range of 10–20 ng/mL, PSAD outperformed fPSAD (AUC = 0.812 vs. 0.742). When PSA > 20 ng/mL, fPSAD was once again superior (AUC = 0.826 vs. 0.789). Decision curve analysis confirmed a positive net benefit for this stratified marker approach. Conclusion: PSAD and fPSAD demonstrate significant predictive value for PCa, particularly csPCa, in AUR patients, with their efficacy being dependent on PSA levels. Therefore, as a hypothesis-generating finding, a stratified approach using fPSAD for PSA 4–10 ng/mL and PSAD for PSA 10–20 ng/mL is proposed, which requires prospective external validation before clinical application.