repeat prostatespecific antigen psa test before prostate biopsy a 20 decrease in psa values is associated with a reduced risk of cancer and particularly of highgrade cancer objectives to analyse the impact of repeating a prostatespecific antigen psa level assessment on prostate biopsy decision in a cohort of men undergoing prostate biopsypatients and methods from 2015 onwards we consecutively enrolled at a single institution in italy men undergoing 12core transrectal ultrasonographyguided prostate needle biopsy indication for prostate biopsy was a psa level of 4 ngml demographic clinical and histopathological data were collected the psa level was tested at enrolment psa1 and 4 weeks later on the day before biopsy psa2 variations in psa level were defined as stable psa2 within a 10 variation stable psa2 within a 20 variation psa2 decreased by 10 psa2 decreased by 20 psa2 increased by 10 psa2 increased by 20 and psa2 4 ngml percentages and multinomial logistic regression were used to analyse biopsy outcomes highgrade cancer was defined as grade group 3results overall 331 patients were enrolled prostate cancer was diagnosed in 153331 46 patients and of them 80153 52 had highgrade disease when compared to the rest of the population patients with a stable psa within 20 variation had a higher risk of prostate cancer odds ratio or 180 p 005 and high grade disease or 256 p 005 patients with a psa2 decreased by 20 had a lower risk of prostate cancer or 037 p 005 and high grade disease or 013 p 005 whilst patients with a psa2 increased by 10 had an increased risk of highgrade prostate cancer or 193 p 005 when psa returned to normal values 4 ngml both risks of prostate cancer and highgrade disease were reduced or 033 and 001 respectively p 0001conclusion in a cohort of italian men undergoing prostate biopsy a reduction of 20 in psa levels significantly reduced the risk of highgrade prostate cancer further multicentre studies should validate our present results