Analysis of PI-RADS 4 cases: Management recommendations for negatively biopsied patients.

•Re-biopsy of obvious, peripheral, negatively biopsied PI-RADS-4-lesions is recommended.•Negatively biopsied transition zone confined PI-RADS-4-lesions with overlaying signs of severe stromal hyperplasia rarely contain csPCa.•Targeted MR/US fusion biopsy alone can miss some csPCa.•In uncertain cases PSAD should be considered for biopsy decision.