Targeted and Systematic Cognitive Freehand Guided Transperineal Biopsy Still a Role for Systematic Biopsy

OBJECTIVES: To assess whether targeted cognitive freehand assisted transperineal biopsies using PrecisionpointTM device still require additional systematic biopsies to avoid missing clinically significant prostate cancer. As a secondary objective we aim to investigate the benefit of a quadrant-only biopsy approach to analyse whether a quadrant or extended target of the quadrant containing the target only would have been equivalent to systematic biopsy. PATIENTS AND METHODS: Patients underwent combined systematic mapping and targeted transperineal prostate biopsies at a single institution. Biopsies were either performed using the PrecisionpointTM device under local anaesthetic (58%, 163/282), intravenous sedation (12%, 34/282) or general anaesthetic (30%, 85/282). Mean (range) systematic 24 (5-42) and target 4.2 (1-11) cores were obtained. MRI scans were reported using the Likert Scale. Clinically significant cancer was defined as Gleason 7 or above. Histopathological results were correlated with the presence of an MRI abnormality within a spatial quadrant and the other adjoining or non-adjoining (opposite) quadrants. Histological concordance with radical prostatectomy specimens was analysed. RESULTS: 282 patients were included in this study. Mean age was 66.8 (36-80) years, median PSA 7.4 (0.91-116) ng/ml and mean prostate volume 45.8 (13-150) cc. 82% (230/282) were primary biopsies, 18% (52/282) were patients on surveillance. 69% (195/282) of all biopsies were identified to have clinically significant disease (Gleason >/=3+4). 84% (237/282) of patients demonstrated any cancer (Gleason >/=3+3). Of patients with clinically significant disease, the target biopsies alone picked up 88% (171/195) with systematic biopsy picking up the additional 12% (24/195) that the target biopsies missed. This altered with Likert score, where 73% of Likert 3 was detected by target, 92% of Likert 4 and 100% of Likert 5. Target biopsies with additional same-quadrant only systematic cores picked up 75% (18/24) of significant cancer that was missed on target only, found in the same quadrant as the target. CONCLUSION: Systematic biopsy is still an important tool when evaluating all patients referred for prostate biopsy but the need is decreased with increasing suspicion on MRI. Patients with very high suspicion of prostate cancer (LIKERT 5) may not require systematic cores, unless representative surrounding biopsies are required for other specific treatment modalities (e.g. focal therapy, or operative planning). More prospective studies are needed to evaluate this in full.