Characterizing the learning curve of MRI-US fusion prostate biopsies

Retrospective analysis of the learning curve in perineal robot-assisted prostate biopsy

INTRODUCTION

Magnetic resonance imaging-transrectal ultrasound (MRI-TRUS)-fusion biopsy (FBx) of the prostate allows targeted sampling of suspicious lesions within the prostate, identified by multiparametric MRI. Due to its reliable results and feasibility, perineal MRI/TRUS FBx is now the gold standard for prostate cancer (PC) diagnosis. There are various systems for performing FBx on the market, for example, software-based, semirobotic, or robot-assisted platform solutions. Their semiautomated workflow promises high process quality independent of the surgeon's experience. The aim of this study was to analyze how the surgeon's experience influences the cancer detection rate (CDR) via targeted biopsy (TB) and the procedure's duration in robot-assisted FBx.

PATIENTS AND METHODS

A total of 1716 men who underwent robot-assisted FBx involving a combination of targeted and systematic sampling between October 2015 and April 2022 were analyzed. We extracted data from the patients' electronic medical records retrospectively. Primary endpoints were the CDR by TB and the procedure's duration. For our analysis, surgeons were divided into three levels of experience: ≤20 procedures (little), 21-100 procedures (intermediate), and >100 procedures (high). Statistical analysis was performed via regression analyses and group comparisons.

RESULTS

Median age, prostate-specific antigen level, and prostate volume of the cohort were 67 (±7.7) years, 8.13 (±9.4) ng/mL, and 53 (±34.2) mL, respectively. Median duration of the procedure was 26 (±10.9) min. The duration decreased significantly with the surgeon's increasing experience from 35.1 (little experience) to 28.4 (intermediate experience) to 24.0 min (high experience) (p < 0.001). Using TB only, significant PC (sPC) was diagnosed in 872/1758 (49.6%) of the men. The CDR revealed no significant correlation with the surgeon's experience in either group comparison (p = 0.907) or in regression analysis (p = 0.65).

CONCLUSION

While the duration of this procedure decreases with increasing experience, the detection rate of sPC in TB is not significantly associated with the experience of the surgeon performing robot-assisted FBx. This robot-assisted biopsy system's diagnostic accuracy therefore appears to be independent of experience.

Learning curve for fusion magnetic resonance imaging targeted prostate biopsy and three-dimensional transrectal ultrasonography segmentation

OBJECTIVE

To report the learning curve of multiple operators for fusion magnetic resonance imaging (MRI) targeted biopsy and to determine the number of cases needed to achieve proficiency.

MATERIALS AND METHODS

All adult males who underwent fusion MRI targeted biopsy between February 2012 and July 2021 for clinically suspected prostate cancer (PCa) in a single centre were included. Fusion transrectal MRI targeted biopsy was performed under local anaesthesia using the Koelis platform. Learning curves for segmentation of transrectal ultrasonography (TRUS) images and the overall MRI targeted biopsy procedure were estimated with locally weighted scatterplot smoothing by computing each operator's timestamps for consecutive procedures. Non-risk-adjusted cumulative sum (CUSUM) methods were used to create learning curves for clinically significant (i.e., International Society of Urological Pathology grade ≥ 2) PCa detection.

RESULTS

Overall, 1721 patients underwent MRI targeted biopsy in our centre during the study period. The median (interquartile range) times for TRUS segmentation and for the MRI targeted biopsy procedure were 4.5 (3.5, 6.0) min and 13.2 (10.6, 16.9) min, respectively. Among the 14 operators with experience of more than 50 cases, a plateau was reached after 40 cases for TRUS segmentation time and 50 cases for overall MRI targeted biopsy procedure time. CUSUM analysis showed that the learning curve for clinically significant PCa detection required 25 to 45 procedures to achieve clinical proficiency. Pain scores ranged between 0 and 1 for 84% of patients, and a plateau phase was reached after 20 to 100 cases.

CONCLUSIONS

A minimum of 50 cases of MRI targeted biopsy are necessary to achieve clinical and technical proficiency and to reach reproducibility in terms of timing, clinically significant PCa detection, and pain.

Current Perceptions, Practice Patterns, and Barriers to Adoption of Transperineal Prostate Biopsy under local anesthesia

OBJECTIVES

To assess perceptions, practice patterns, and barriers to adoption of Transperineal prostate biopsy (TPBx) under local anesthesia.

METHODS

Providers from Michigan Urological Surgery Improvement Collaborative (MUSIC) and Pennsylvania Urologic Regional Collaborative (PURC) were administered an online survey to assess beliefs and educational needs regarding TPBx. Providers were divided into those who performed or did not perform TPBx. The MUSIC and PURC registry were queried to assess TPBx utilization. Descriptive analytics and bivariate analysis determined associations between provider/practice demographics and attitudes.

RESULTS

Since 2019, TPBx adoption has increased more than 2-fold to 7.0% and 16% across MUSIC and PURC practices, respectively. Of 350 urologists invited to participate in a survey, a total of 91 complete responses were obtained with 21 respondents (23%) reported performing TPBx. Participants estimated the learning curve was <10 procedure for TPBx performers and non-performers. No significant association was observed between learning curve and provider age/practice setting. The major perceived benefits of TPBx were decreased risk of sepsis, improved cancer detection rate and antibiotic stewardship. The most commonly cited challenges to implementation included access to equipment and patient experience. Urologists performing TPBx reported learning curve as an additional barrier, while those not performing TPBx reported duration of procedure.

CONCLUSIONS

Access to equipment and patient experience concerns remain substantial barriers to adoption of TPBx. Dissemination of techniques utilizing existing equipment and optimization of local anesthetic protocols for TPBx may help facilitate the continued adoption of TPBx.

Prostate cancer detection and complications of MRI-targeted prostate biopsy using cognitive registration, software-assisted image fusion or in-bore guidance: a systematic review and meta-analysis of comparative studies

BACKGROUND

Three primary strategies for MRI-targeted biopsies (TB) are available: Cognitive TB (COG-TB), MRI-US Fusion TB (FUS-TB), and In Bore TB (IB-TB). Despite nearly a decade of practice, a consensus on the preferred approach is lacking, with previous studies showing comparable PCa detection rates among the three methods.

METHODS

We conducted a search of PubMed, EMBASE, PubMed, Web of Science, and Scopus databases from 2014 to 2023, to identify studies comparing at least two of the three methods and reporting clinically significant PCa (csPCa) detection rates. The primary and secondary outcomes were to compare the csPCa and insignificant prostate cancer (iPCa, ISUP GG 1) detection rates between TB techniques. The tertiary outcome was to compare the complication rate between TB techniques. Detection rates were pooled using random-effect models. Planned sensitivity analyses included subgroup analysis according to the definition of csPCa and positive MRI, previous biopsy status, biopsy route, prostate volume, and lesion characteristics.

RESULTS

A total of twenty studies, involving 4928 patients, were included in the quantitative synthesis. The meta-analysis unveiled comparable csPCa detection rates among COG-TB (0.37), FUS-TB (0.39), and IB-TB (0.47). iPCa detection rate was also similar between TB techniques (COG-TB: 0.12, FUS-TB: 0.17, IB-TB: 0.18). All preplanned sensitivity analyses were conducted and did not show any statistically significant difference in the detection of csPCa between TB methods. Complication rates, however, were infrequently reported, and when available, no statistically significant differences were observed among the techniques.

CONCLUSIONS

This unique study, exclusively focusing on comparative research, indicates no significant differences in csPCa and iPCa detection rates between COG-TB, FUS-TB, and IB-TB. Decisions between these techniques may extend beyond diagnostic accuracy, considering factors such as resource availability and operator preferences. Well-designed prospective studies are warranted to refine our understanding of the optimal approach for TB in diverse clinical scenarios.

Expect the unexpected: investigating discordant prostate MRI and biopsy results

OBJECTIVES

To evaluate discrepant radio-pathological outcomes in biopsy-naïve patients undergoing prostate MRI and to provide insights into the underlying causes.

MATERIALS AND METHODS

A retrospective analysis was conducted on 2780 biopsy-naïve patients undergoing prostate MRI at a tertiary referral centre between October 2015 and June 2022. Exclusion criteria were biopsy not performed, indeterminate MRI findings (PI-RADS 3), and clinically insignificant PCa (Gleason score 3 + 3). Patients with discrepant findings between MRI and biopsy results were categorised into two groups: MRI-negative/Biopsy-positive and MRI-positive/Biopsy-negative (biopsy-positive defined as Gleason score ≥ 3 + 4). An expert uroradiologist reviewed discrepant cases, retrospectively re-assigning PI-RADS scores, identifying any missed MRI targets, and evaluating the quality of MRI scans. Potential explanations for discrepancies included MRI overcalls (including known pitfalls), benign pathology findings, and biopsy targeting errors.

RESULTS

Patients who did not undergo biopsy (n = 1258) or who had indeterminate MRI findings (n = 204), as well as those with clinically insignificant PCa (n = 216), were excluded, with a total of 1102 patients analysed. Of these, 32/1,102 (3%) were classified as MRI-negative/biopsy-positive and 117/1102 (11%) as MRI-positive/biopsy-negative. In the MRI-negative/Biopsy-positive group, 44% of studies were considered non-diagnostic quality. Upon retrospective image review, target lesions were identified in 28% of cases. In the MRI-positive/Biopsy-negative group, 42% of cases were considered to be MRI overcalls, and 32% had an explanatory benign pathological finding, with biopsy targeting errors accounting for 11% of cases.

CONCLUSION

Prostate MRI demonstrated a high diagnostic accuracy, with low occurrences of discrepant findings as defined. Common reasons for MRI-positive/Biopsy-negative cases included explanatory benign findings and MRI overcalls.

CLINICAL RELEVANCE STATEMENT

This study highlights the importance of optimal prostate MRI image quality and expertise in reducing diagnostic errors, improving patient outcomes, and guiding appropriate management decisions in the prostate cancer diagnostic pathway.

KEY POINTS

• Discrepancies between prostate MRI and biopsy results can occur, with higher numbers of MRI-positive/biopsy-negative relative to MRI-negative/biopsy-positive cases. • MRI-positive/biopsy-negative cases were mostly overcalls or explainable by benign biopsy findings. • In about one-third of MRI-negative/biopsy-positive cases, a target lesion was retrospectively identified.

The learning curve for robotic-assisted transperineal MRI/US fusion-guided prostate biopsy

Transperineal fusion prostate biopsy has a considerable learning curve (LC). Robotic-assisted transperineal MRI/Ultrasound fusion-guided biopsy (RA-TP-FBx) may have an easier LC due to automatization. We aimed to assess the LC of RA-TP-FBx and analyze its most difficult steps. We prospectively analyzed cases randomized to a biopsy-naïve urology resident, the chief resident, and an expert urologist in RA-TP-FBx (controls). We also analyzed consecutive cases in the LC of the expert. The LC was defined by procedure time, PCa detection rate (including stratification by PI-RADS), entrustable professional activities (EPA) assessment scores, and the NASA task load index. We collectively performed 246 RA-TP-FBx with the Mona Lisa device. Procedure time for residents decreased steeply from maximum 53 min to minimum 10 min, while the mean procedure time for the expert was 9 min (range 17-5 min). PCa detection for PI-RADS-4 lesions was 57% for the naïve resident, 61% for the chief resident and 62% for the expert. There was also no difference in Pca detection for PI-RADS-4 lesions when comparing the first and second half of the experts' biopsies (p = 0.8). Maximum EPA score was registered after 22 cases. Workload steeply declined. Proficient RA-TP-FBx performance appears feasible after 22 cases regardless of previous experience.

Surgeon seniority and experience have no effect on CaP detection rates using MRI/TRUS fusion-guided targeted biopsies

OBJECTIVE

To determine (i) whether urologist seniority and experience are associated with prostate cancer (CaP) and clinically significant CaP (csCaP) detection rates using magnetic resonance imaging/ultrasound (MRI/US) fusion-guided targeted biopsies, taking multiparametric magnetic resonance imaging (mpMRI) as the reference standard, and (ii) if cancer detection rates (CDR) differ across regions of the prostate using Dickinson's 27-sector map, regardless of seniority.

METHODS

We retrospectively reviewed a consecutive series of patients with suspicion of prostate cancer who underwent targeted and systematic biopsies at 1 center by 1 of 7 urologists (2 seniors and 5 juniors) between January 1, 2016 and December 31, 2021, following positive mpMRI.

RESULTS

The cohort comprised 403 patients (454 lesions) aged 67.7±6.8. The combined (junior and senior) CDR was 57% for CaP and 28% for csCaP. There were no differences in CDR between junior and senior urologists for CaP (58% vs. 55%, P = 0.538) or csCaP (29% vs. 26%, P = 0.58). A general trend was observed for the learning curve, which indicated increasing CDR with urologist experience. Across the 27 sectors, combined CDR ranged between 39% and 99% for CaP and 1% to 67% for csCaP. When grouping anterior vs. posterior sectors, there were no differences in combined CDR of CaP (64% vs. 67%, P = 0.48) and csCaP (31% vs. 38%, P = 0.19) CONCLUSIONS: Urologist seniority is not associated with CDR, urologist experience tends to improve cancer detection, and CDR does not differ between the anterior and posterior regions of the prostate.

Impact of operator expertise on transperineal free-hand mpMRI-fusion-targeted biopsies under local anaesthesia for prostate cancer diagnosis: a multicenter prospective learning curve

PURPOSE

Transperineal mpMRI-targeted fusion prostate biopsies (TPFBx) are recommended for prostate cancer diagnosis, but little is known about their learning curve (LC), especially when performed under local anaesthesia (LA). We investigated how operators' and institutions' experience might affect biopsy results.

METHODS

Baseline, procedure and pathology data of consecutive TPFBx under LA were prospectively collected at two academic Institutions, from Sep 2016 to May 2019. Main inclusion criterion was a positive MRI. Endpoints were biopsy duration, clinically significant prostate cancer detection rate on targeted cores (csCDR-T), complications, pain and urinary function. Data were analysed per-centre and per-operator (with ≥ 50 procedures), comparing groups of consecutive patient, and subsequently through regression and CUSUM analyses. Learning curves were plotted using an adjusted lowess smoothing function.

RESULTS

We included 1014 patients, with 27.3% csCDR-T and a median duration was 15 min (IQR 12-18). A LC for biopsy duration was detected, with the steeper phase ending after around 50 procedures, in most operators. No reproducible evidence in favour of an impact of experience on csPCa detection was found at operator's level, whilst a possible gentle LC of limited clinical relevance emerged at Institutional level; complications, pain and IPSS variations were not related to operator experience.

CONCLUSION

The implementation of TPFBx under LA was feasible, safe and efficient since early phases with a relatively short learning curve for procedure time.

The impact of a second MRI and re-biopsy in patients with initial negative mpMRI-targeted and systematic biopsy for PIRADS ≥ 3 lesions

OBJECTIVE

To evaluate the proportions of detected prostate cancer (PCa) and clinically significant PCa (csPCa), as well as identify clinical predictors of PCa, in patients with PI-RADS >  = 3 lesion at mpMRI and initial negative targeted and systematic biopsy (initial biopsy) who underwent a second MRI and a re-biopsy.

METHODS

A total of 290 patients from 10 tertiary referral centers were included. The primary outcome measures were the presence of PCa and csPCa at re-biopsy. Logistic regression analyses were performed to evaluate predictors of PCa and csPCa, adjusting for relevant covariates.

RESULTS

Forty-two percentage of patients exhibited the presence of a new lesion. Furthermore, at the second MRI, patients showed stable, upgrading, and downgrading PI-RADS lesions in 42%, 39%, and 19%, respectively. The interval from the initial to repeated mpMRI and from the initial to repeated biopsy was 16 mo (IQR 12-20) and 18 mo (IQR 12-21), respectively. One hundred and eight patients (37.2%) were diagnosed with PCa and 74 (25.5%) with csPCa at re-biopsy. The presence of ASAP on the initial biopsy strongly predicted the presence of PCa and csPCa at re-biopsy. Furthermore, PI-RADS scores at the first and second MRI and a higher number of systematic biopsy cores at first and second biopsy were independent predictors of the presence of PCa and csPCa. Selection bias cannot be ruled out.

CONCLUSIONS

Persistent PI-RADS ≥ 3 at the second MRI is suggestive of the presence of a not negligible proportion of csPca. These findings contribute to the refinement of risk stratification for men with initial negative MRI-TBx.

Does experience change the role of systematic biopsy during MRI-fusion biopsy of the prostate?

PURPOSE

To determine the role of biopsy experience regarding a potential benefit of additional systematic biopsies and fusion failures during MRI-targeted biopsy of the prostate.

SUBJECTS/PATIENTS AND METHODS

We retrospectively evaluated 576 men undergoing transrectal (MRI)-targeted biopsy of the prostate by seven residents in urology between November 2019 and March 2022. Benefit of systematic biopsies (detection of ISUP ≥ 2 PCa (clinically significant PCa (csPCa)) solely in systematic biopsies) and fusion failure (detection of csPCa during systematic biopsies in the area of a reported MRI-lesion and no detection of csPCa in targeted biopsy) were compared by growing biopsy experience levels. Multivariable regression analyses were calculated to investigate the association with benefit of systematic biopsies and fusion failure.

RESULTS

The overall PCa detection rate was 72% (413/576). A benefit of systematic biopsies was observed in 11% (63/576); of those, fusion failure was seen in 76% (48/63). Benefit of systematic biopsies and fusion failure were more common among residents with very low experience compared to highly experienced residents (18% versus 4%, p = 0.026; 13% versus 3%, p = 0.015, respectively). Increasing biopsy experience was associated with less benefit from systematic biopsies (OR: 0.98, 95% CI 0.97-0.99) and less fusion failure (OR: 0.98, 95% CI 0.97-0.99).

CONCLUSIONS

The benefit of systematic biopsies following targeted biopsy decreases with growing biopsy experience. The higher risk of fusion failure among inexperienced residents necessitates systematic biopsies to ensure the detection of csPCa. Further prospective trials are warranted before a targeted only approach can be recommended in routine clinical practice.

Transperineal vs. transrectal prostate biopsies under local anesthesia: A prospective cohort study on patient tolerability and complication rates

OBJECTIVES

An increasing number of urologists is switching from transrectal (TR) to transperineal (TP) biopsy procedures for the diagnosis of prostate cancer. Local anesthesia (LA) might be advantageous in terms of patient management, risks and costs. We aimed to evaluate the tolerability and complication rates of TP prostate biopsy performed under LA.

METHODS

This is a monocentric, prospective, comparative, observational cohort study. Between July 2020 and July 2021 we included 128 consecutive patients (TR, n = 61; TP, n = 67), with a suspicion of prostate cancer. Transrectal vs. transperineal prostate biopsies were both performed under LA. To evaluate the tolerability we administered a validated visual analog pain score (VAS) during the different steps of the biopsy procedure as well as at 12-, 24- and 48-hours post procedure. The International Prostate Symptom Score (IPSS) questionnaire was administered before the procedure and at the same time intervals. The presence of hematuria, hematospermia, rectal blood loss, acute retention and febrile urinary tract infection (UTI) were also monitored.

RESULTS

There were no significant differences in pain or IPSS between groups, except for a significantly higher pain score during the LA of the prostate in the TP group. In general, complication rates were similar, only the prevalence of hematuria at 24 hours was significantly higher in the TP group, as was rectal blood loss at 12 hours postprocedure in the TR group.

CONCLUSIONS

In conclusion, our study showed that transperineal prostate biopsy under local anesthesia could be performed with similar pain scores and complication rates, compared to the transrectal procedure.

Intra-practice Urologist-level Variation in Targeted Fusion Biopsy Outcomes

OBJECTIVE

To examine the extent to which the urologist performing biopsy contributes to variation in prostate cancer detection during fusion-guided prostate biopsy.

METHODS

All men in the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry who underwent fusion biopsy at Michigan Medicine from August 2017 to March 2019 were included. The primary outcomes were clinically significant cancer detection rate (defined as Gleason Grade ≥2) in targeted cores and clinically significant cancer detection on targeted cores stratified by PI-RADS score. Bivariate and multivariable logistic regression analyses were performed.

RESULTS

A total of 1133 fusion biopsies performed by 5 providers were included. When adjusting for patient age, PSA, race, family history, prostate volume, clinical stage, and PI-RADS score, there was no significant difference in targeted clinically significant cancer detection rates across providers (range = 38.5%-46.9%, adjusted P-value = .575). Clinically significant cancer detection rates ranged from 11.1% to 16.7% in PI-RADS 3 (unadjusted P = .838), from 24.6% to 43.4% in PI-RADS 4 (adjusted P = .003), and from 69.4% to 78.8% in PI-RADS 5 (adjusted P = .766) lesions.

CONCLUSION

There was a statistically significant difference in clinically significant prostate cancer detection in PI-RADS 4 lesions across providers. These findings suggest that even among experienced providers, variation at the urologist level may contribute to differences in clinically significant cancer detection rates within PI-RADS 4 lesions. However, the relative impact of biopsy technique, radiologist interpretation, and MR acquisition protocol requires further study.

Prostate Cancer Detection and Complications of Transperineal Versus Transrectal Magnetic Resonance Imaging-fusion Guided Prostate Biopsies

OBJECTIVE

To assess the rates of detection of clinically significant prostate cancer (csPCa) and complications associated with transperineal (TP) and transrectal (TR) biopsy approaches to magnetic resonance imaging (MRI)-fusion targeted biopsy.

MATERIALS AND METHODS

We retrospectively identified men who underwent TP or TR MRI-targeted biopsy with concurrent systematic random biopsy from August 2020 to August 2021. Primary outcomes were detection rates of csPCa and 30-day complication rates between the 2 MRI-biopsy groups. Data were additionally stratified by prior biopsy status.

RESULTS

A total of 361 patients were included in the analysis. No demographic differences were observed. No significant differences were observed between TP and TR approaches on any of the outcomes of interest. TR MRI-targeted biopsies identified csPCa in 47.2% of patients, and TP MRI-targeted biopsies identified csPCa in 48.6% of patients (P = .78). No significant differences were observed in csPCa detection between the 2 approaches for patients on active surveillance (P = .59), patients with prior negative biopsy (P = .34), and patients who were biopsy naïve (P = .19). Complication rates did not vary by approach (P = .45).

CONCLUSION

Neither the identification of csPCa by MRI-targeted biopsy nor rates of complications differed significantly based on a TR or TP approach. No differences were seen between MRI-targeted approaches based on prior biopsy or active surveillance status.

Combination of fusion guided multiparametric MRI-transrectal US with systematic biopsy of the prostate for the detection of clinically significant prostate cancer: A prospective single-center study

PURPOSE

To investigate the diagnostic efficacy of fusion guided multiparametric MRI (mpMRI)-transrectal ultrasound (TRUS) biopsy versus systematic biopsy of the prostate in patients with suspicion of prostate cancer.

METHODS

A total of 185 patients with PI-RADS 3 lesions or higher underwent fusion guided targeted and systematic prostate biopsy. Histology of samples was correlated with PI-RADS score and biopsy method for each patient.

RESULTS

A total of 81/185 (43.8%) cases positive for cancer were detected; 23/81 (28.4%) cases with clinically insignificant prostate cancer-insPCa and 58/81 (71.6%) cases with clinically significant prostate cancer-csPCa. There was a statistically significant difference in the overall detection of adenocarcinomas between methods (p = .035, McNemar test). Moreover, there was a statistically significant difference in the detection of insPCa between the two methods (p = .004, McNemar test). Systematic biopsy detected 13 patients with insPCa more (14.4%) than the targeted biopsy method. However, there is no statistical difference in the detection rate of csPCa between the two methods (p = 1, McNemar test). When both techniques were combined more cases of csPCa were detected.

CONCLUSION

The combined implementation of fusion-guided targeted mpMRI-TRUS and systematic biopsy of the prostate provides higher detection number of csPCa, compared to each method alone. The potential of fusion-guided mpMRI-TRUS biopsy of the prostate needs to be further assessed since each method has its limitations; therefore, systematic prostate biopsy still plays an important role in clinical practice.

The design and validation of a low-cost trans perineal (TP) prostate biopsy simulator for training: improving trainees' confidence and cognitive targeting skills

PURPOSE

The aim of this research was to create a novel and low-cost TP prostate biopsy simulator that has face, content and construct validity with high educational value.

METHODS

This research developed a trans perineal prostate (TP) biopsy simulator using 3D-printed moulds and tissue-mimicking materials. Important regions (anterior, mid, and posterior zones) were coded with different colours. Ultrasound visible abnormal lesions were embedded in the prostate phantom. Expert and novice participants in TP biopsies were recruited. Essential skills were identified through the consensus of six experts. These skills were assessed through tasks performed by participants. This included the accuracy and timing of systematic and target biopsies. Immediate feedback was determined by the colour of the biopsy cores taken. A survey was distributed to evaluate its realism and educational value.

RESULTS

The material cost of one simulator was £7.50. This simulator was proven to have face, content, and construct validity. There was a significant difference (p = 0.02) in the accuracy of systematic biopsies between both experts and novices. Significant difference was also observed (p = 0.01), in accurately identifying target lesion on ultrasound between both groups. Participants rated the overall realism of the simulator 4.57/5 (range 3-5). 100% of the experts agreed that introducing this simulator to training will be beneficial. 85.7% of the participants strongly agree that the simulator improved their confidence in TP biopsies.

CONCLUSION

There is value in integrating this proof-of-concept TP prostate biopsy simulator into training. It has highly rated educational value and has face, content, and construct validity.

[Common errors, pitfalls, and management of complications of prostate biopsy : The most common diagnostic and procedural challenges of transrectal fusion prostate biopsy in the initial diagnosis of clinically significant prostate cancer]

BACKGROUND

Transrectal (TR) prostate biopsy is the gold standard in diagnosis of prostate cancer (PC). It requires a precise and safe technique for sample acquisition.

OBJECTIVE

Several approaches will be discussed to avoid overdiagnosis, false-negative results, and complications of the procedure.

MATERIALS AND METHODS

We analyzed national and European guidelines, systematic reviews, meta-analyses, as well as prospective and retrospective studies to describe current trends in indication and performance of biopsies.

RESULTS

Incorporation of risk calculators and magnetic resonance imaging (MRI) into daily routine reduces biopsy rates and results in a more precise diagnosis of clinically significant prostate cancer (csPC). Combination of random- and MRI-fusion guided biopsy-but also extending the radius of sampling by 10 mm beyond the MRI lesion and a transperineal (TP) sampling approach - lead to a higher tumor-detection rate. Bleeding is the most common complication after prostate biopsy and is usually self-limiting. Postbiopsy infection rates can be reduced through TP biopsy.

CONCLUSION

TR MRI-fusion guided biopsy is a widely acknowledged tool in primary diagnostics of csPC. Higher detection rates and safety can be achieved through a TP sampling approach.

Index lesion contouring on prostate MRI for targeted MRI/US fusion biopsy - Evaluation of mismatch between radiologists and urologists

PURPOSE

Mistargeting of focal lesions due to inaccurate segmentations can lead to false-negative findings on MRI-guided targeted biopsies. The purpose of this retrospective study was to examine inter-reader agreement of prostate index lesion segmentations from actual biopsy data between urologists and radiologists.

METHOD

Consecutive patients undergoing transperineal MRI-targeted prostate biopsy for PI-RADS 3-5 lesions between January 2020 and December 2021 were included. Agreement between segmentations on T2w-images between urologists and radiologists was assessed with Dice similarity coefficient (DSC) and 95 % Hausdorff distance (95 % HD). Differences in similarity scores were compared using Wilcoxon test. Differences depending on lesion features (size, zonal location, PI-RADS scores, lesion distinctness) were tested with Mann-Whitney U test. Correlation with prostate signal-intensity homogeneity score (PSHS) and lesion size was tested with Spearman's rank correlation.

RESULTS

Ninety-three patients (mean age 64.9 ± 7.1y, median serum PSA 6.5 [4.33-10.00]) were included. Mean similarity scores were statistically significantly lower between urologists and radiologists compared to radiologists only (DSC 0.41 ± 0.24 vs. 0.59 ± 0.23, p < 0.01; 95 %HD 6.38 ± 5.45 mm vs. 4.47 ± 4.12 mm, p < 0.01). There was a moderate and strong positive correlation between DSC scores and lesion size for segmentations from urologists and radiologists (ρ = 0.331, p = 0.002) and radiologists only (ρ = 0.501, p < 0.001). Similarity scores were worse in lesions ≤ 10 mm while other lesion features did not significantly influence similarity scores.

CONCLUSION

There is significant mismatch of prostate index lesion segmentations between urologists and radiologists. Segmentation agreement positively correlates with lesion size. PI-RADS scores, zonal location, lesion distinctness, and PSHS show no significant impact on segmentation agreement. These findings could underpin benefits of perilesional biopsies.

Should Transperineal Prostate Biopsy Be the Standard of Care?

PURPOSE OF REVIEW

We reviewed the advantages and disadvantages of transperineal prostate biopsy (TP-bx) to evaluate its potential role as the standard of care for prostate biopsy.

RECENT FINDINGS

Studies have suggested no difference in prostate cancer (PCa) detection rate between TP-bx and transrectal biopsy (TR-bx) but have suggested potentially increased detection of anterior prostate tumors. Advances in anesthetic technique have obviated the need for sedation thus allowing TP-bx to become an office-based procedure, which in turn can decrease the overall cost of TP-bx. Furthermore, given the low rate of infectious complications after TP-bx, some have foregone peri-procedural antibiotics without a change in the rate of infectious complications. Recent procedural advances have made TP-bx a tolerable, office-based procedure. Given the similar diagnostic performance and the benefits for the patient and community, TP-bx should become the standard of care for prostate biopsy for most patients. Future efforts should address the barriers for more universal adoption.

Vector Prostate Biopsy: A Novel Magnetic Resonance Imaging/Ultrasound Image Fusion Transperineal Biopsy Technique Using Electromagnetic Needle Tracking Under Local Anaesthesia

BACKGROUND

Prostate magnetic resonance imaging (MRI) is now standard for assessment of suspected prostate cancer (PCa). A variety of approaches to MRI-based targeting has revolutionised prostate biopsies.

OBJECTIVE

To describe the procedure and show the accuracy and tolerability of a novel Vector MRI/ultrasound fusion transperineal (TP) biopsy technique that uses electromagnetic (EM) needle tracking under local anaesthesia (LA).

DESIGN, SETTING, AND PARTICIPANTS

Vector prostate biopsy using BiopSee fusion software, EM tracking technology, and transrectal ultrasound was performed in 69 patients meeting the biopsy criteria in two UK centres between September 2020 and August 2022.

SURGICAL PROCEDURE

Stepper-mounted rectal ultrasound images were fused with MRI scans. LA was applied into two defined perineal tracks and a needle sheath with an EM sensor was inserted. The biopsy needle was directed precisely through the sheath to MRI targets under EM tracking. Biopsies were taken without antibiotic prophylaxis.

MEASUREMENTS

Cancer detection (any PCa; grade group ≥2), side effects, and patient experience measures were recorded.

RESULTS AND LIMITATIONS

Cancer detection in patients with Likert 4-5 lesions was 98% for any PCa and 83% for grade group ≥2. According to the 50 questionnaires returned, 42 patients (84%) reported no or minimal pain, while 40 (80%) reported no or minimal discomfort. No episodes of postoperative urinary retention occurred, and only one patient required treatment for infection. Limitations include the low patient number and incomplete responses to questionnaires.

CONCLUSIONS

This novel Vector technique provides a feasible and tolerable procedure for MRI/ultrasound fusion TP biopsy under LA, with high cancer detection rates. This is achieved while maintaining patient comfort and with minimal rates of complications.

PATIENT SUMMARY

We report a novel technique that uses electromagnetic needle tracking to perform highly accurate and comfortable prostate biopsies through the perineum under local anaesthetic.

Learning Curve of Transperineal MRI/US Fusion Prostate Biopsy: 4-Year Experience

This study aimed to evaluate the learning curve of transperineal magnetic resonance imaging (MRI)/ultrasound (US) fusion biopsy in a team composed of a single surgeon, a single radiologist, and a single pathologist. We prospectively enrolled 206 patients undergoing MRI/US fusion prostate biopsy and divided them into four cohorts by the year of biopsy. We analyzed temporal changes in clinically significant prostate cancer (csPC) detection rate, percentage of positive cores on biopsy, and Gleason upgrading rate after radical prostatectomy. The csPC detection rate by MRI/US fusion targeted biopsy (TB) increased significantly (from 35.3% to 60.0%, p = 0.01). With increased experience, the csPC detection rates for small (≤1 cm) and anterior target lesions gradually increased (from 41.2% to 51.6%, p = 0.5; from 54.5% to 88.2%, p = 0.8, respectively). The percentage of positive cores on TB increased significantly (from 18.4% to 44.2%, p = 0.001). The Gleason upgrading rate gradually decreased (from 22.2% to 11.1%, p = 0.4). In conclusion, with accumulated experience and teamwork, the csPC detection rate by TB significantly increased. Multidisciplinary team meetings and a free-hand biopsy technique were the key factors for overcoming the learning curve.

Feasibility and preliminary clinical tolerability of low-field MRI-guided prostate biopsy

OBJECTIVE

We evaluate the clinical feasibility of a portable, low-field magnetic resonance imaging (MRI) system for prostate cancer (PCa) biopsy.

METHODS

A retrospective analysis of men who underwent a 12-core systematic transrectal ultrasound-guided prostate biopsy (SB) and a low-field MRI guided transperineal targeted biopsy (MRI-TB). Comparison of the detection of clinically significant PCa (csPCa) (Gleason Grade [GG] ≥ 2) by SB and low field MRI-TB, stratified by Prostate Imaging Reporting & Data System (PI-RADS) score, prostate volume, and prostate serum antigen (PSA) was performed.

RESULTS

A total of 39 men underwent both the MRI-TB and SB biopsy. Median (interquartile range [IQR]) age was 69.0 (61.5-73) years, body mass index (BMI) was 28.9 kg/m² (25.3-34.3), prostate volume was 46.5 cc (32-72.7), and PSA was 9.5 ng/ml (5.5-13.2). The majority (64.4%) of patients had PI-RADS ≥ 4 lesions and 25% of lesions were anterior on pre-biopsy MRII. Cancer detection rate (CDR) was greatest when combining SB and MRI-TB (64.1%). MRI-TB detected 74.3% (29/39) cancers. Of which, 53.8% (21/39) were csPCa while SB detected 42.5% (17/39) csPCa (p = 0.21). In 32.5% (13/39) of cases, MRI-TB upstaged the final diagnosis, compared to 15% (6/39) of cases in which SB upstaged the final diagnosis (p = 0.11).

CONCLUSION

Low-field MRI-TB is clinically feasible. Although future studies on the accuracy of MRI-TB system are needed, the initial CDR is comparable to those seen with fusion-based prostate biopsies. A transperineal and targeted approach may be beneficial in patients with higher BMI and anterior lesions.

Adverse Pathology after Radical Prostatectomy of Patients Eligible for Active Surveillance-A Summary 7 Years after Introducing mpMRI-Guided Biopsy in a Real-World Setting

OBJECTIVE

Over the last decade, active surveillance (AS) of low-risk prostate cancer has been increasing. The mpMRI fusion-guided biopsy of the prostate (FBx) is considered to be the gold standard in preoperative risk stratification. However, the role of FBx remains unclear in terms of risk stratification of low-risk prostate cancer outside high-volume centers. The aim of this study was to evaluate adverse pathology after radical prostatectomy (RP) in a real-world setting, focusing on patients diagnosed with Gleason score (GS) 6 prostate cancer (PCa) and eligible for AS by FBx.

SUBJECTS AND METHODS

Between March 2015 and March 2022, 1297 patients underwent FBx at the Department of Urology, Ludwig-Maximilians-University of Munich, Germany. MpMRI for FBx was performed by 111 different radiology centers. FBx was performed by 14 urologists from our department with different levels of experience. In total, 997/1297 (77%) patients were diagnosed with prostate cancer; 492/997 (49%) of these patients decided to undergo RP in our clinic and were retrospectively included. Univariate and multivariable logistic regression analyses were performed to evaluate clinical and histopathological parameters associated with adverse pathology comparing FBx and RP specimens. To compare FBx and systematic randomized biopsies performed in our clinic before introducing FBx (SBx, n = 2309), we performed a propensity score matching on a 1:1 ratio, adjusting for age, number of positive biopsy cores, and initial PSA (iPSA).

RESULTS

A total of 492 patients undergoing FBx or SBx was matched. In total, 55% of patients diagnosed with GS 6 by FBx were upgraded to clinically significant PCa (defined as GS ≥ 7a) after RP, compared to 52% of patients diagnosed by SBx (p = 0.76). A time delay between FBx and RP was identified as the only correlate associated with upgrading. A total of 5.9% of all FBx patients and 6.1% of all SBx patients would have been eligible for AS (p > 0.99) but decided to undergo RP. The positive predictive value of AS eligibility (diagnosis of low-risk PCa after biopsy and after RP) was 17% for FBx and 6.7% for SBx (p = 0.39).

CONCLUSIONS

In this study, we show, in a real-world setting, that introducing FBx did not lead to significant change in ratio of adverse pathology for low-risk PCa patients after RP compared to SBx.

Robot-Assisted Magnetic Resonance Imaging-Targeted versus Systematic Prostate Biopsy; Systematic Review and Meta-Analysis

INTRODUCTION

Robot-assisted devices have been recently developed for use in prostate biopsy. However, it is possible advantages over standard biopsy remain unclear. We aimed to assess the diagnostic performance and safety of robot-assisted targeted (RA-TB) and systematic prostate biopsies (RA-SB).

METHODS

A systematic literature search was performed in MEDLINE and Scopus databases. The detailed search strategy is available at Prospero (CRD42021269290). The primary outcome was the clinically significant prostate cancer (PCa) detection rate. The secondary outcomes included the overall detection rate of PCa, cancer detection rate per core, and complications.

RESULTS

The clinically significant cancer detection rate, overall cancer detection rate, and "per patient" did not significantly differ between RA-TB and RA-SB [OR = 1.02 (95% CI 0.83; 1.26), p = 0.05, I² = 62% and OR = 0.95 (95% CI 0.78; 1.17), p = 0.17, I² = 40%, respectively]. There were no differences in the clinically insignificant cancer detection rate "per patient" between RA-TB and RA-SB [OR = 0.81 (95% CI 0.54; 1.21), p = 0.31, I² = 0%]. RA-TB had a significantly higher cancer detection rate "per core" [OR = 3.01 (95% CI 2.77; 3.27), p < 0.0001, I² = 96%].

CONCLUSION

RA-TB and RA-SB are both technically feasible and have comparable clinical significance and overall PCa detection rates.

Are Urologists Ready for Interpretation of Multiparametric MRI Findings? A Prospective Multicentric Evaluation

Aim: To assess urologists’ proficiency in the interpretation of multiparametric magnetic resonance imaging (mpMRI). Materials and Methods: Twelve mpMRIs were shown to 73 urologists from seven Italian institutions. Responders were asked to identify the site of the suspicious nodule (SN) but not to assign a PIRADS score. We set an a priori cut-off of 75% correct identification of SN as a threshold for proficiency in mpMRI reading. Data were analyzed according to urologists’ hierarchy (UH; resident vs. consultant) and previous experience in fusion prostate biopsies (E-fPB, defined as <125 vs. ≥125). Additionally, we tested for differences between non-proficient vs. proficient mpMRI readers. Multivariable logistic regression analyses (MVLRA) tested potential predictors of proficiency in mpMRI reading. Results: The median (IQR) number of correct identifications was 8 (6−8). Anterior nodules (number 3, 4 and 6) represented the most likely prone to misinterpretation. Overall, 34 (47%) participants achieved the 75% cut-off. When comparing consultants vs. residents, we found no differences in terms of E-fPB (p = 0.9) or in correct identification rates (p = 0.6). We recorded higher identification rates in urologists with E-fBP vs. their no E-fBP counterparts (75% vs. 67%, p = 0.004). At MVLRA, only E- fPB reached the status of independent predictor of proficiency in mpMRI reading (OR: 3.4, 95% CI 1.2−9.9, p = 0.02) after adjusting for UH and type of institution. Conclusions: Despite urologists becoming more familiar with interpretation of mpMRI, their results are still far from proficient. E-fPB enhances the proficiency in mpMRI interpretation.

[Image-guided biopsy of the prostate gland]

The recommendations on carrying out a multiparametric magnetic resonance imaging (mpMRI) for the primary diagnostics and during active surveillance of prostate cancer, include as a consequence an image-guided sampling from conspicuous areas. In doing so, the information on the localization provided by mpMRI is used for a targeted biopsy of the area suspected of being a tumor. The targeted sampling is mainly performed under sonographic control and after fusion of MRI and ultrasound but can also be (mostly in special cases) carried out directly in the MRI scanner. In an ultrasound-guided biopsy, it is vital to coregister the MR images with the ultrasound images (segmentation of the contour of the prostate and registration of suspect findings). This coregistration can either be carried out cognitively (transfer by the person performing the biopsy alone) or software based. Each method shows specific advantages and disadvantages in the prioritization between diagnostic accuracy and resource expenditure.

Selecting patients for magnetic resonance imaging cognitive versus ultrasound fusion biopsy of the prostate: A within‐patient comparison

Objectives

To compare overall agreement between magnetic resonance imaging (MRI)–ultrasound (US) fusion biopsy (FB) and MRI cognitive fusion biopsy (CB) of the prostate and determine which factors affect agreement for prostate cancer (PCa) who underwent both modalities in a prospective within‐patient protocol.

Patients and Methods

From August 2017 to January 2021, patients with at least one Prostate Imaging Reporting & Data System (PI‐RADS) 3 or higher lesion on multiparametric MRI underwent transrectal FB and CB in a prospective within‐patient protocol. CB was performed for each region of interest (ROI), followed by FB, followed by standard 12 core biopsy. Patients who were not on active surveillance were analysed. The primary endpoint was agreement for any PCa detection. McNemar's test and kappa statistic were used to analyse agreement. Chi‐square test, Fisher's exact test and Wilcoxon rank sum test were used to analyse disagreement across clinical and MRI spatial variables. A multivariable generalized mixed‐effect model was used to compare the interaction between select variables and fusion modality. Statistics were performed using SAS and R.

Results

Ninety patients and 98 lesions were included in the analysis. There was moderate agreement between FB and CB (k = 0.715). McNemar's test was insignificant (p = 0.285). Anterior location was the only variable associated with a significant variation in agreement, which was 70% for anterior lesions versus 89.7% for non‐anterior lesions (p = 0.035). Discordance did not vary significantly across other variables. In a mixed‐effect model, the interaction between anterior location and use of FB was insignificant (p = 0.411).

Conclusion

In a within‐patient protocol of patients not on active surveillance, FB and CB performed similarly for PCa detection and with moderate agreement. Anterior location was associated with significantly higher disagreement, whereas other patient and lesion characteristics were not. Additional studies are needed to determine optimal biopsy technique for sampling anterior ROI.

Impact of Surgeon's Experience in Rigid versus Elastic MRI/TRUS-Fusion Biopsy to Detect Significant Prostate Cancer Using Targeted and Systematic Cores

Simple Summary

For the transfer of suspicious lesions in magnetic resonance imaging (MRI) to ultrasound in prostate fusion biopsy, biopsy platforms can be distinguished by rigid or elastic image registration. This study evaluates the detection rate of these different platforms for transperineal fusion-guided prostate biopsy to detect clinically significant prostate cancer under consideration of the surgeon’s learning curve. In our cohort, rigid and elastic registration systems showed a similar prostate cancer detection rate in experienced surgeons, whereas novices seem to benefit from rigid fusion. In the total cohort, targeted fusion biopsy with a rigid registration system outperformed elastic registration target biopsy with a superior significant prostate cancer detection rate, each compared to systematic saturation biopsy. Thus, rigid target biopsy aided in reducing targeting errors that result in missing MRI-visualized significant prostate cancer. These results can provide valuable decision support in selecting a biopsy fusion platform to increase the detection rate and risk stratification of prostate cancer, especially at the beginning of the surgeon’s learning curve.

Abstract

Multiparametric magnetic resonance imaging (mpMRI) and MRI/ultrasound fusion-targeted prostate biopsy (FB) have excellent sensitivity in detecting significant prostate cancer (sPC). FB platforms can be distinguished by rigid (RTB) or elastic image registration (ETB). We compared RTB and ETB by analyzing sPC detection rates of both RTB and ETB at different stages of the surgeons’ learning curve. Patients undergoing RTB between 2015–2017 (n = 502) were compared to patients undergoing ETB from 2017–2019 (n = 437). SPC detection rates were compared by Chi-square-test on patient-basis. Combination of transperineal systematic biopsy and each TB served as reference and sub-analyses were performed for different grades of surgeon’s experience. In the RTB subgroup, 233 men (46%) had sPC, compared to 201 (46%) in the ETB subgroup. RTB alone detected 94% of men with sPC and ETB 87% (p = 0.02). However, for at least intermediate-experienced surgeons (>100 FB), no differences occurred between RTB and ETB. In the total cohort, at least intermediate-experienced surgeons detected significantly more sPC (10%, p = 0.008) than novices. Thus, targeted transperineal MRI/TRUS-FB with a RTB registration system showed a similar sPC detection rate to ETB in experienced surgeons but a superior sPC detection rate to ETB in the total cohort. Low-experienced surgeons seem to benefit from RTB.

Transrectal Ultrasound-Guided Biopsy Should Continue to Be a Standard of Care for The Detection of Prostate Cancer

For men choosing to screen for prostate cancer (PCa), biopsy remains critical for diagnosis. While transrectal ultrasound-guided (TRUS) biopsy has been the standard of care for many years, recent concerns regarding post-procedural infection have led to increased interest in prostatic sampling via the transperineal (TP) approach. However, TRUS biopsy features important patient-related and physician/practice-related advantages compared to the TP method, and there are several useful strategies to effectively mitigate infectious concerns. The benefits associated with TRUS biopsy, particularly patient comfort and efficient clinical workflow, are further accentuated by several key shortcomings associated with switching to the TP approach. Herein, we present an argument in favor of maintaining TRUS biopsy as standard practice, discussing significant topics including infectious complications, practice workflow and cost, cancer detection rates, and patient experience.

A Prospective Study Comparing Cancer Detection Rates of Transperineal Prostate Biopsies Performed by Junior Urologists versus a Senior Consultant in a Real-World Setting

INTRODUCTION

Prostate biopsy (PB) is a typical daily practice method for the diagnosis of prostate cancer (PCa). This study aimed to compare the PCa detection rates and peri- and postoperative complications of PB among 3 residents and a consultant.

PATIENTS AND METHODS

A total of 343 patients who underwent PB between August 2018 and July 2019 were involved in this study. Residents were systematically trained for 2 weeks by a consultant for performing systematic biopsy (SB) and targeted biopsy (TB). And then, 3 residents and the consultant performed PB independently every quarter due to routine rotation in daily practice. The peri- and postoperative data were collected from a prospectively maintained database (www.pc-follow.cn). The primary outcome and secondary outcome were to compare the PCa detection rates and complications between the residents and consultant, respectively.

RESULTS

There was no significant difference between the residents and consultant in terms of overall PCa detection rates of SB and TB or further stratified by prostate-specific antigen value and prostate imaging reporting and data system (PI-RADS) scores. We found the consultant had more TB cores (175 cores vs. 86-114 cores, p = 0.043) and shorter procedural time (mean 16 min vs. 19.7-20.1 min, p < 0.001) versus the residents. The complication rate for the consultant was 6.7% and 5%-8.2% for the residents, respectively (p = 0.875).

CONCLUSIONS

The residents could get similar PCa detection and complication rates compared with that of the consultant after a 2-week training. However, the residents still need more cases to shorten the time of the biopsy procedure.

Anterior and apical samplings during transperineal image-guided prostate biopsy

INTRODUCTION

Concurrent systematic biopsies during image-guided targeted biopsies of the prostate were found to improve the detection rate of clinically significant prostate cancer (CSPC). However, these biopsies do not routinely include anterior or apical sampling. We aimed to evaluate the significance of anterior and apical samplings during combined biopsies.

METHODS

After obtaining institutional review board approval we identified 303 consecutive patients who underwent transperineal combined biopsies of the prostate between 2017-2020. Systematic biopsies were obtained from the peripheral zone, anterior zone, and apex. Study outcomes included CSPC and any cancer on anterior or apical biopsies. Logistic regression analyses were used to evaluate the association between pre-biopsy characteristics and study outcomes.

RESULTS

Median prostatic-specific-antigen value was 6.8 ng/dL. Most patients had stage T1c disease (77%). Overall, combined biopsies detected CSPC in 87 patients (29%). Any cancer and CSPC in the anterior zone were found in 54 (18%) and 19 (6%) patients, respectively. Any cancer and CSPC in the apex were found in 54 (18%) and 16 (5%) patients, respectively. Anterior/apical samplings upgraded the pathological result in 19 patients (6%). Logistic regression analyses demonstrated that PI-RADS 5 lesions predicted the presence of CSPC in both the anterior zone (OR = 8, 95%CI = 3-22, P <0.001) and apex (OR = 4, 95%CI = 1-10, P = 0.01).

CONCLUSIONS

Avoiding anterior and apical samplings during prostate biopsy does not result in substantial under-diagnosis of significant cancer. However, these areas are easily accessible using the transperineal approach and should be sampled in selected patients, particularly those with PI-RADS 5 lesions.

Number of cores needed to diagnose prostate cancer during MRI targeted biopsy decreases after the learning curve

INTRODUCTION

We hypothesized that the number of cores needed to detect prostate cancer would decrease with increasing MRI-targeted biopsy (TBx) experience.

METHODS

All patients undergoing TBx at our institution from May 2017 to August 2019 were enrolled in a prospectively maintained database. Five biopsy cores were obtained from each lesion ≥3 on PI-RADS v2.0 followed by a systematic 12-core biopsy. To assess learning curve, the study population was divided into quartiles by sequential biopsies. Clinically significant prostate cancer (csPC) was defined as Gleason Grade Group 2 or higher.

RESULTS

377 patients underwent prostate biopsy (533 lesions); 233 lesions (44%) were positive for prostate cancer and 173 lesions (32%) were csPC. There was a significant decline in the number of cores required for diagnosing any cancer (P < 0.001) and csPC (P < 0.05) after the first quartile. There was no difference when stratifying by PI-RADS score or lesion volume. Within the first quartile, limiting the biopsy to 3 cores would miss 16.2% of csPC, decreasing to 6.6% after approximately 100 patients.

CONCLUSION

MRI TBx is associated with a learning curve of approximately 100 cases. Four or 5 cores should be considered during the initial experience, but thereafter, 3 cores per lesion is sufficient to detect csPC.

Analyzing the learning curves of a novice and an experienced urologist for transrectal magnetic resonance imaging-ultrasound fusion prostate biopsy

Background

The aim of the current study was to evaluate and compare the learning curves of transrectal magnetic resonance imaging-ultrasound fusion biopsy for two urologists with different backgrounds (Operator 1: experienced, self-trained and Operator 2: novice, trained by a mentor/MRI reading courses).

Methods

A cohort of 400 patients who underwent fusion prostate biopsy in our department was analyzed. The learning curves were assessed in terms of overall and clinically significant prostate cancer (PCa) detection rates, percentage of positive biopsy cores/targeted and the percentage of PCa tissue on positive targeted cores.

Results

Increasing trends were observed for both urologists in terms of all biopsy outcomes during the study time. For the novice urologist, a significant increase was observed for overall PCa detection rate, but not for clinically significant disease (25.44%, P=0.04/15%, P=0.145). Operator 1 showed an increasing diagnosis yield of clinically significant disease up to 104 cases. Similar cancer detection rates were observed when comparing the first and last biopsies performed by both operators. Multivariate analysis adjusted for age, PSA, prostate volume, lesion diameter and PIRADS score showed an increase of PCa detection with 51% for every 52 biopsies performed (P=0.022).

Conclusions

When starting with magnetic resonance imaging-ultrasound fusion prostate biopsy, mentoring and prostate magnetic resonance imaging reading training allow a novice urologist to demonstrate a good initial PCa detection rate. After about 52 cases, he reached a stable PCa and clinically significant PCa detection rate, that was similar to that of an experienced urologist.

Techniques and Outcomes of MRI-TRUS Fusion Prostate Biopsy

PURPOSE OF REVIEW

The goal of this study is to review recent findings and evaluate the utility of MRI transrectal ultrasound fusion biopsy (FBx) techniques and discuss future directions.

RECENT FINDINGS

FBx detects significantly higher rates of clinically significant prostate cancer (csPCa) than ultrasound-guided systematic prostate biopsy (SBx), particularly in repeat biopsy settings. FBx has also been shown to detect significantly lower rates of clinically insignificant prostate cancer. In addition, a dedicated prostate MRI can assist in more accurately predicting the Gleason score and provide further information regarding the index cancer location, prostate volume, and clinical stage. The ability to accurately evaluate specific lesions is vital to both focal therapy and active surveillance, for treatment selection, planning, and adequate follow-up. FBx has been demonstrated in multiple high-quality studies to have improved performance in diagnosis of csPCa compared to SBx. The combination of FBx with novel technologies including radiomics, prostate-specific membrane antigen positron emission tomography (PSMA PET), and high-resolution micro-ultrasound may have the potential to further enhance this performance.

Recent Advances and Current Role of Transperineal Prostate Biopsy

"Approximately 1 million prostate biopsies are performed each year in the United States. This procedure has traditionally been performed using a transrectal approach, which is associated with a significant risk of infectious complications including sepsis. In recent years, transperineal prostate biopsy has been increasingly adopted due to its lower associated infectious risk. In this review, we explore the benefits of the transperineal approach for performing prostate biopsy and detail technical advancements that have allowed for this procedure to now be routinely performed in the outpatient settings under local anesthesia."

Multiparametric MRI-ultrasound fusion prostate biopsy in patients without prior diagnosis of prostate cancer: beyond centers of excellence

PURPOSE

Multiparametric magnetic resonance imaging (mpMRI)-ultrasound (US) fusion prostate biopsy (FBx) has demonstrated increased accuracy for prostate cancer detection at designated centers of excellence. There is a concern if their results can be reproduced in smaller centers. Here, we evaluate the outcomes of FBx from a smaller academic center.

METHODS

A retrospective review of patients without a prior diagnosis of prostate cancer undergoing FBx from January 2014 to November 2019 was performed. Histopathological results were grouped into low-risk disease (Grade Group 1), intermediate-risk disease (Grade Group 2 and 3), and high-risk disease (Grade Group 4 or 5). Clinically significant (CS) prostate cancer was defined as Grade Group ≥ 2.

RESULTS

Five hundred and six men were included. Median age (IQR) and PSA (IQR) were 65.2 (60.3-70.2) years and 6.9 (5.2-9.7) ng/ml, respectively. There was no difference in overall cancer detection between FBx and SBx (53.6% vs 56.4% p = .1507). CS cancer detection was significantly higher with FBx (39.6% vs 35.3, p = .0275). FBx also outperformed SBx in diagnosing CS disease in patients with prior history of negative prostate biopsy (36.9% vs 27.9%, p < .001).

CONCLUSION

FBx detects a higher proportion of clinically significant disease and a lower proportion of clinically insignificant disease compared to SBx, in line with outcomes demonstrated by centers of excellence.

Transperineal prostate biopsy: The modern gold standard to prostate cancer diagnosis

In patients suspicious for prostate cancer, a prostate biopsy should be performed. Biopsies are possible either by the transrectal or transperineal routes. Compared with the transrectal prostate biopsy (TRPBx), transperineal prostate biopsy (TPPBx) offers a non-inferior cancer detection rate (CDR), especially in patients undergoing re-biopsy for persistently elevated PSA and in cases of active surveillance (AS), in which TPPBx seems to be superior. Moreover, the transperineal route achieves superior sampling of the anterior and apical regions, especially after previous multiple negative TRPBx. Infectious complications are nullified due to avoidance of needle passage through the rectal mucosa, and there is a highly significant evidence of reduced fever and sepsis rates when compared with TRPBx, with maintaining acceptable urinary retention rates. This is an important upcoming topic due to the increasing antibiotic resistance rates, thus reducing periinterventional hospitalization and health care costs. To date, TPPBx is perfectly feasible in the inpatient and out-patient settings and under local anesthesia, characterized by a moderate learning curve and a good reproducibility. By applying mpMRI as a diagnostic tool, clinically significant prostate cancer (csPCa) detection seems to be comparable to transrectal MRI-fusion biopsy (TR-MRIFBx). Finally, focal treatment of localized disease is currently performed exclusively through a TP approach.

A noninferiority within-person study comparing the accuracy of transperineal to transrectal MRI-US fusion biopsy for prostate-cancer detection

BACKGROUND

Magnetic resonance imaging (MRI) and ultrasound (US) fusion prostate-biopsies can be performed in a transrectal (TR-fusion) or transperineal (TP-fusion) approach. Prospective comparative evidence is limited. In this study we compared the detection rate of clinically-significant prostate-cancer (csPCa) within an index lesion between TR and TP-fusion.

PATIENTS AND METHODS

This was a prospective, noninferiority, and within-person trial. Men scheduled for MRI-US-fusion with a discrete MRI PI-RRAD ≥ 3 lesion were included. A dominant index lesion was determined for each subject and sampled by TR and TP-fusion during the same session. The order of biopsies was randomized and equipment was reset to avoid chronological and incorporation bias. For each subject, the index lesion was sampled 4-6 times in each approach. All biopsies were performed using Navigo fusion software (UC-Care, Yokneam, Israel). csPCa was defined as: Grade Group ≥ 2 or cancer-core length ≥ 6 mm. We used a noninferiority margin of 10% and a one-sided alpha level of 5%.

RESULTS

Seventy-seven patients completed the protocol. Median age was 68.2 years (IQR:64.2-72.2), median PSA was 8.9 ng/ml (IQR:6.18-12.2). Ten patients (13%) were biopsy naive, others (87%) had a previous biopsy. csPCa was detected in 32 patients (42%). All of these cases were detected by TP-fusion, while only 20 (26%) by TR-fusion. Absolute difference for csPCa diagnosis was 15.6 (CI 90% 27.9-3.2%) in favor of TP-fusion (p = 0.029). TP-fusion was noninferior to TR-fusion. The lower boundary of the 90% confidence-interval between TP-fusion and TR-fusion was greater than zero, therefore TP-fusion was also found to be superior. Exploratory subgroup analyses showed TP-fusion was consistently associated with higher detection rates of csPCa compared with TR-fusion in patient and index-lesion derived subgroups (size, location, PI-RADS, PSA, and biopsy history).

CONCLUSIONS

In this study, TP-fusion biopsies were found to be noninferior and superior to TR-fusion biopsies in detecting csPCa within MRI-visible index lesion. Centers experienced in both TP and TR-fusion should consider these results when choosing biopsy method.