Transperineal Multiparametric Magnetic Resonance Imaging–Ultrasound Fusion Targeted Prostate Biopsy Combined with Standard Template Improves Prostate Cancer Detection

Abstract

Purpose: Transperineal (TP) prostate biopsy provides an effective approach to prostate cancer (PCa) detection. Although transrectal targeted biopsy has been well described, the specific advantage of the standard TP template or TP targeted biopsy using multiparametric (mp) magnetic resonance imaging (MRI)ultrasound (US) fusion remains less understood and without consensus. Materials and Methods: We identified all men who underwent a transperineal standard 20-core template in addition to a targeted biopsy with mpMRI-US fusionguided software from September 2019 to February 2021. We assessed and compared clinical, MRI and biopsy characteristics between standard TP template and fusion targeted biopsies. Results: A total of 301 men underwent TP fusion biopsy during the study period. Target lesions on MRI were sampled with 3 targeted cores per patient (IQR 3e4). The overall cancer detection rate was 74.1% and 63.5% by standard template and targeted biopsy, respectively, of which 52.5% and 59.7% were clinically significant (cs) PCa. Combined csPCa detection rate was 62.2%. Of 176 cases with a cancer diagnosis by both biopsy methods, 18.8% were upgraded with targeted biopsies while 18.2% were upgraded with template biopsies. Conclusions: In men with suspicious lesions on mpMRI, TP MRI fusion-guided biopsies combined with standard template provide a higher overall cancer detection rate and higher detection rate of csPCa than the standard template or targeted biopsy alone. In the setting of a suspicious mpMRI prostate lesion, targeted plus standard template should be included as part of the TP biopsy procedure.

Pooled outcomes of performing freehand transperineal prostate biopsy with the PrecisionPoint Transperineal Access System

“…Of these, 17 (18%) met inclusion criteria and underwent full‐text analysis (Figure S1 ). One study 24 was excluded from the pooled analysis of CDRs due to overlapping patients with a subsequently published report 13 that included a larger sample size. However, only the earlier of the two reports included data on procedural complications and so was included in our analysis of this endpoint.…”

“…In two studies, 12–14% of clinically significant cancers that were missed on targeted biopsy were detected on systematic sampling of the prostate 20,21 . Further support for performing systematic biopsies comes from a study by Kim et al, in which up to 18.2% of cancers detected on targeted biopsy were upgraded on systematic biopsy 13 . Although some reports found that targeted biopsies alone were sufficient to detect clinically significant disease using the transperineal approach, this may be due to sampling of fewer systematic cores contributing to decreased sensitivity 36,37 .…”

“… 20 , 21 Further support for performing systematic biopsies comes from a study by Kim et al, in which up to 18.2% of cancers detected on targeted biopsy were upgraded on systematic biopsy. 13 Although some reports found that targeted biopsies alone were sufficient to detect clinically significant disease using the transperineal approach, this may be due to sampling of fewer systematic cores contributing to decreased sensitivity. 36 , 37 In addition, the added value of systematic biopsy to targeted biopsy may vary depending on the PI‐RADS score of targeted lesions.…”

“…In recent years, the limitations of the original freehand technique for performing transperineal prostate biopsy have been overcome by the introduction of a purpose‐built, probe‐mounted needle guide that includes a common access cannula known as the PrecisionPoint Transperineal Access System (Perineologic, Cumberland, MD). 5 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 Following its approval by the United States Food and Drug Administration in 2016, this device facilitated the rapid adoption of transperineal prostate biopsy worldwide and led to widespread calls for the complete abandonment of the transrectal approach to prostate biopsy. 25 , 26 In this report, we provide the results of a systematic review of the available literature on the outcomes and complications of performing transperineal prostate biopsies using this novel device.…”

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“…2 Although in the past decade, multiparametric MRI has positioned itself in the assessment of prostate cancer, it mainly secures the identification of the index tumor, whereas less clinically (in)significant tumors can still be missed. 3,4 Hence, also template biopsies have obvious limitations and also may still miss smaller-sized tumors, 5,6 although global guidelines still include template biopsies in the assessment to select patients for focal therapy. 7…”