Outcomes of combination MRI-targeted and transperineal template biopsy in restaging low-risk prostate cancer for active surveillance

Objective:Active surveillance(AS)offers a strategy to reduce overtreatment and now is a widely accepted treatment option for low-risk prostate cancer.An ideal tool for risk-stratification would detect aggressive cancers and exclude such men from taking up AS in the first place.We evaluate if a combination of transperineal template biopsy with magnetic resonance imaging(MRI)-targeted biopsy identifies significant prostate cancer amongst men initially diagnosed with low-risk prostate cancer.Methods:This prospective,single-blinded study included men with low-risk prostate cancer(D’Amico’s Criteria)diagnosed on conventional transrectal ultrasound-guided biopsy.Patients first underwent multiparametric MRI of the prostate
6 weeks after initial biopsy.Each suspicious lesion is mapped and assigned a Prostate Imaging Reporting and Data System(PIRADS)score.Template biopsy is first performed with the surgeon blinded to MRI findings followed by MRI-targeted biopsy using a robotic transperineal biopsy platform.Results:The age of the 19 men included is 65.4±4.9 years(mean±SD).Prostate specific antigen(PSA)at diagnosis and at the time of transperineal biopsy were comparable(7.3±1.7 ng/mL and 7.0±1.8 ng/mL,p Z 0.67),so were prostate volumes(34.2±8.9 mL and 32.1±13.4 mL,p Z 0.28).MRI-targeted biopsy had a higher percentage of cancer detection per core compared to template biopsy(11.7%vs.6.5%,p Z 0.02),this was more than 3 times superior for Gleason 7 disease(5.9%vs.1.6%,p<0.01).Four of 18(22.2%)patients with MRI lesions had significant disease with MRI-targeted biopsy alone.Three of 19 patients(15.8%)had significant disease with template biopsy alone.In combination,both techniques upclassified five patients(26.3%),all of whom underwent radical prostatectomy.Whole mount histology confirmed tumour location and grade.All six patients with PIRADS 5 lesions had cancer detected(66.6%significant disease).Conclusion:A combination of MRI-targeted and template biopsy may optimally risk-classify“low-risk”patients diagnosed on initial conventional transrectal ultrasonography(TRUS)prostate biopsy.

The results of transperineal versus transrectal prostate biopsy： a systematic review and meta-analysis

This systematic review was performed to compare the efficacy and complications of transperineal （TP） vs. transrectal （TR） prostate biopsy. A systematic research of PUBM ED, EMBASE and the Cochrane Library was performed to identify all clinical controlled trials on prostate cancer （PCa） detection rate and complications achieved by TP and TR biopsies. Prostate biopsies included sextant, extensive and saturation biopsy procedures. All patients were assigned to a TR group and a TP group. Subgroup analysis was performed according to prostate-specific antigen （PSA） levels and digital rectal examination （DRE） findings. The Cochrane Collaboration＇s RevMan 5.1 software was used for the meta-analysis. A total of seven trials, including three randomized controlled trials （RCTs） and four casecontrol studies （CCS）, met our inclusion criteria. There was no significant difference in the cancer detection rate between the sextant TR and TP groups （risk difference （RD）, -0.02; 95% confidence interval （CI）, -0.08-0.03; P=0.34）. Meta-analysis for RCTs combined with CCS showed that there was no difference in the cancer detection rate between the extensive TR and TP group （RD, -0.01; 95% CI, -0.05-0.04; P=0.81）. There was no significant difference in PCa detection rate between the saturation TR and TP approaches （31.4% vs. 25.7%, respectively;P=0.3）. There were also no significant differences in cancer detection between the TR and TP groups in each subgroup. Although the data on complications were not pooled for the meta-analysis, no significant difference was found when comparing TR and TP studies. TR and TP biopsies were equivalent in terms of efficiency and related complications. TP prostate biopsy should be an available and alternative procedure for use by urologists.

Cognitive magnetic resonance imaging-ultrasound fusion transperineal targeted biopsy combined with randomized biopsy in detection of prostate cancer

BACKGROUND Prostate cancer(PCa)is one of the most common cancers among men.Various strategies for targeted biopsy based on multiparametric magnetic resonance imaging(mp-MRI)have emerged,which may improve the accuracy of detecting clinically significant PCa in recent years.AIM To investigate the diagnostic efficiency of a template for cognitive MRIultrasound fusion transperineal targeted plus randomized biopsy in detecting PCa.METHODS Data from patients with an increasing prostate-specific antigen(PSA)level but less than 20 ng/mL and at least one lesion suspicious for PCa on MRI from December 2015 to June 2018 were retrospectively analyzed.All patients underwent cognitive fusion transperineal template-guided targeted biopsy followed by randomized biopsy outside the targeted area.A total of 127 patients with complete data were included in the final analysis.A multivariable logistic regression analysis was conducted,and a two-sided P<0.05 was considered statistically significant.RESULTS PCa was detected in 66 of 127 patients,and 56 cases presented clinically significant PCa.Cognitive fusion targeted biopsy alone detected 59/127 cases of PCa,specifically 52/59 cases with clinically significant PCa and 7/59 cases with clinically insignificant PCa.A randomized biopsy detected seven cases of PCa negative on targeted biopsy,and four cases had clinically significant PCa.PSA density(OR:1.008,95%CI:1.003-1.012,P=0.001;OR:1.006,95%CI:1.002-1.010,P=0.004)and Prostate Imaging-Reporting and Data System(PI-RADS)scores(both P<0.001)were independently associated with the results of cognitive fusion targeted biopsy combined with randomized biopsy and targeted biopsy alone.CONCLUSION This single-centered study proposed a feasible template for cognitive MRIultrasound fusion transperineal targeted plus randomized biopsy.Patients with higher PSAD and PI-RADS scores were more likely to be diagnosed with PCa.

Role of transperineal template biopsy in prostate cancer

Prostate cancer is the most common neoplasm diagnosed in men. Whilst treatment modalities have progressed, diagnostic investigations in terms of biopsy methods have been assessed but there is no consensus of when the different diagnostic methods in terms of transrectal ultrasound(TRUS) or transperineal template(TPT) should be utilised. TPT biopsy has a higher diagnostic yield than TRUS in those with a primary biopsy, in those with previous negative biopsies with TRUS as well as those undergoing saturation biopsies. Despite the increased likelihood of diagnosing cancer with TPT than TRUS this maybe secondary to the increasednumber of biopsies being utilised. However there is no consensus regarding the ideal number of biopsies that should be utilised with TPT. Furthermore it is felt that the increased number of biopsies utilised with TPT is associated the higher complication rates with TPT. The role of TPT biopsy is recognised in those with previous negative biopsies with transrectal ultrasound but further work is required regarding the ideal number of biopsies. Furthermore, it is felt that TPT biopsy may have a role in primary biopsy.

Impact of delay from transperineal biopsy to radical prostatectomy upon objective measures of cancer control

Objective:Treatment delays in prostate cancer have been characterised,although not explicitly in men undergoing transperineal prostate biopsies.We aimed to determine if delays to radical prostatectomy correlate with adverse outcomes using a contemporary population-based cohort of men diagnosed by transperineal biopsies.Methods:This study analysed men with prostate cancer of the International Society for Urological Pathology grade group≥2,diagnosed by transperineal prostate biopsies who underwent prostatectomy,using the prospectively data from 1 January 2014 to 30 June 2018 Prostate Cancer Outcomes Registry-Victoria.Data were analysed according to stratified demographic and disease characteristics.Time intervals from biopsy(28,60,90,120,and 270 days)were compared using odds ratios and regression analyses for proportion of upgrading,early biochemical recurrence,pT3 disease at prostatectomy,and positive surgical margins.Results:In total,2008 men were analysed.There were 306(16.7%)men with upgrading,151(8.4%)with biochemical recurrence,1068(54.1%)with pT3 disease,and 464(23.1%)with positive surgical margins(percentages excluded patients with missing data).All adverse outcomes studied were significantly associated with higher prostate-specific antigen and grade at diagnosis.Delays of 120-270 days did not adversely alter the incidence of Gleason upgrading,pT3,or recurrence.Delays(most frequent 60-89 days,28%)were associated with positive surgical margins but not monotonically.Regression modelling demonstrated no increased likelihood of most adverse outcomes for up to 270 days.Conclusion:Men with prostate cancer of grade group≥2 diagnosed through transperineal biopsy may wait up to 270 days for a prostatectomy without a greater likelihood of upgrading,pT3 disease,positive surgical margins,or biochemical recurrence.

Does needle calibre affect pain and complication rates in patients undergoing transperineal prostate biopsy？ A prospective, randomized trial

Transperineal prostate biopsy is a procedure that can be used to obtain histological samples from the prostate. To improve both the quality of the biopsy core samples and prostate cancer detection, we are currently performing a prospective, randomized trial comparing prostate biopsy samples obtained using an 18 G-needle to those obtained using a 16 G-needle. The aim of this preliminary study was to evaluate pain and complication rates in both groups in order to assess whether performing a prostate biopsy with a larger calibre needle is a feasible procedure. One hundred and eighty-seven patients undergoing transperineal prostate biopsy were prospectively evaluated and divided into two groups. The first group （94 patients, Group A） received a transperineal prostate biopsy using a 16 G-needle and the second group （93 patients, Group B） underwent transperineal prostate biopsy with an 18 G-needle. Anaesthesia was obtained with a single perineal injection at the prostatic apex in all subjects. A visual analogue scale （VAS） and facial expression scale （FES） were used to assess pain during multiple steps of the procedure in each group. A detailed questionnaire was used to obtain information about drug use because it could potentially influence the pain and complications that patients experienced. Two weeks after the procedure, early and late complications were evaluated. Statistical analysis was carried out using non-parametric tests. Prostate Specific Antigen （PSA） and drug use were similar at baseline between the two groups. Pain during prostate biopsy, which was measured with both the VAS and FES instruments, did not differ significantly between the 18- and 16 G-needle groups, and no significant differences were found in early or late complication rates between the groups. Transperineal prostate biopsy with a 16 G-needle is a feasible Further studies with larger patient populations are required to prostate cancer detection rates. procedure in terms of pain and complication rates. assess whether or not this procedure can improve

Prostate chronic inflammation type Ⅳ and prostate cancer risk in patients undergoing first biopsy set:Results of a large cohort study

Objective:In prostate specimens,chronic inflammatory infiltrate(CII)type Ⅳ has been detected,but its association with prostate cancer(PCa)is controversial.The aim of the present study is to investigate on associations of CII with PCa detection in patients undergoing prostate first biopsy set.Methods:Ultrasound transrectal-guided biopsies by the transperineal approach were retrospectively evaluated in 441 consecutive patients.The study excluded patients who were in active surveillance,prostate specific antigen(PSA)
30 ng/mL,re-biopsies,incidental PCa after transurethral resection of the prostate(TURP),less than 14 cores or metastatic.Analysis of population and subpopulations(with or without PCa)was performed by statistical methods which included ManneWhitney(U test),KruskaleWallis test,Chi-squared statistic,logistic regression.Multivariate logistic regression models predicting mean probability of PCa detection were established.Results:PCa detection rate was 46.03%.Age,PSA,prostate volume(PV),prostate intraepithelial neoplasia(PIN)and CII were the significant independent predictors of PCa detection.PV(OR Z 0.934)and CII(OR Z 0.192)were both negative independent predictors.CII was a significant negative independent predictor in multivariate logistic regression models predicting the mean probability of PCa detection by age,PSA and PV.The inverse association of CII with PCa does not necessary mean protection because of PSA confounding.Conclusion:In a population of patients undergoing prostate first biopsy set,CII was a strong negative independent predictor of PCa detection.CII type Ⅳ should be considered as an adjunctive parameter in re-biopsy or active surveillance protocols.

Comparison of Cognitive Registration Transrectal Ultrasound-Guided Targeted Biopsy of Prostate to Systematic 12-Core Biopsy: A Retrospective, Multicentre Study

Introduction: Prostate cancer (PCa) is the third most prevalent cancer among Malaysian males, often diagnosed at advanced stages, leading to suboptimal outcomes. While transrectal ultrasound-guided systematic biopsy (TRUS-SB) is the primary diagnostic method, prebiopsy multiparametric magnetic resonance imaging (mpMRI) is gaining popularity in identifying suspicious lesions. This study addresses the lack of comprehensive investigations into the efficacy of cognitive registration TRUS targeted biopsy (COG-TB) compared to conventional TRUS-SB, considering the resource limitations of the Malaysian healthcare system. Materials and Methods: A retrospective cohort study was conducted in two Malaysian healthcare facilities. 116 adult patients with a prostate-specific antigen (PSA) level of more than 4 ng/mL who underwent both COG-TB and TRUS-SB between October 2020 and March 2022 were included. Primary outcomes were cancer detection rate and histopathological outcomes, including Gleason score. Results: COG-TB showed a higher overall cancer detection rate (50%) compared to TRUS-SB (44%). Clinically significant cancer detection rates were similar between COG-TB and TRUS-SB (37.1%). Further analysis revealed that both COG-TB and TRUS-SB detected clinically significant cancer in 30.2% of patients, did not detect it in 56.0%, and had conflicting findings in 16 patients (p Conclusion: COG-TB and TRUS-SB have comparable detection rates for clinically significant prostate cancer, with COG-TB showing a higher tendency to detect insignificant prostate cancer. Further studies comparing these methods are warranted.

Role of Hiraoka's transurethral detachment of the prostate combined with biopsy of the peripheral zone during the same session in patients with repeated negative biopsies in the diagnosis of prostate cancer

BACKGROUND Persistent suspicion of prostate cancer(PCa)due to a rising prostate-specific antigen(PSA)level after repeated negative biopsies is a serious challenge in clinical practice.AIM To determine the role of Hiraoka’s transurethral detachment of the prostate(TUDP)combined with biopsy of the peripheral zone during the same session in patients with repeated negative biopsies in the diagnosis of PCa.METHODS We retrospectively evaluated the records of 10 patients who were eligible for inclusion in our hospital between December 2012 and August 2017.Patient demographics,a family history of PCa,the number of biopsies,prostate volume,pathological examination,and perioperative PSA level were obtained.RESULTS Two of 10 patients were pathologically diagnosed with PCa after surgery;the Gleason scores were 4+4 and 4+3,respectively.Both patients subsequently underwent laparoscopic radical prostatectomy.The median PSA levels preoperatively,and 3 mo and 1 year postoperatively in the other eight patients who were diagnosed with benign prostate hyperplasia after surgery were 19.10 ng/mL,1.10 ng/mL,and 1.15 ng/mL,respectively.The adjusted P values of the 3-mo and 1-year post-operative PSA level vs pre-operative PSA level were 0.003 and 0.026,respectively.None of the patients had increased PSA levels or PCa detected after a median 35 mo of follow-up.CONCLUSION TUDP combined with peripheral zone biopsy may improve the detection rate of PCa in patients with repeated negative biopsies.The PSA level declined rapidly in patients who had negative pathological examinations after TUDP,which remained stable 1 year after surgery.

Targeted prostate biopsy： value of multiparametric magnetic resonance imaging in detection of localized cancer

Prostate cancer is the second most common cancer in men, with 1.1 million new cases worldwide reported by the World Health Organization in one recent year. Transrectal ultrasound （TRUS）-guided biopsy has been used for the diagnosis of prostate cancer for over 2 decades, but the technique is usually blind to cancer location. Moreover, the false negative rate of TRUS biopsy has been reported to be as high as 47%. Multiparametric magnetic resonance imaging （mp-MRI） includes T1- and T2-weighted imaging as well as dynamic contrast-enhanced （DCE） and diffusion-weighted imaging （DWI）. mp-MRI is a major advance in the imaging of prostate cancer, enabling targeted biopsy of suspicious lesions. Evolving targeted biopsy techniquesmincluding direct in-bore biopsy, cognitive fusion and software-based MRI-ultrasound （MRI-US） fusion--have led to a several-fold improvement in cancer detection compared to the earlier method. Importantly, the detection of clinically significant cancers has been greatly facilitated by targeting, compared to systematic biopsy alone. Targeted biopsy via MRI-US fusion may dramatically alter the way prostate cancer is diagnosed and managed.

Magnetic resonance imaging-guided prostate biopsydA review of literature

Objective:Multiparametric magnetic resonance imaging(MP-MRI)helps to identify lesion of prostate with reasonable accuracy.We aim to describe the various uses of MP-MRI for prostate biopsy comparing different techniques of MP-MRI guided biopsy.Materials and methods:A literature search was performed for“multiparametric MRI”,“MRI fusion biopsy”,“MRI guided biopsy”,“prostate biopsy”,“MRI cognitive biopsy”,“MRI fusion biopsy systems”,“prostate biopsy”and“cost analysis”.The search operation was performed using the operator“OR”and“AND”with the above key words.All relevant systematic reviews,original articles,case series,and case reports were selected for this review.Results:The sensitivity of MRI targeted biopsy(MRI-TB)is between 91%e93%,and the specificity is between 36%e41%in various studies.It also has a high negative predictive value(NPV)of 89%e92%and a positive predictive value(PPV)of 51%e52%.The yield of MRI fusion biopsy(MRI-FB)is similar,if not superior to MR cognitive biopsy.In-bore MRI-TB had better detection rates compared to MR cognitive biopsy,but were similar to MR fusion biopsy.Conclusions:The use of MRI guidance in prostate biopsy is inevitable,subject to availability,cost,and experience.Any one of the three modalities(i.e.MRI cognitive,MRI fusion and MRI in-bore approach)can be used.MRI-FB has a fine balance with regards to accuracy,practicality and affordability.

Feasibility of prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques

BACKGROUND Routinely, after receiving prostate specific antigen (PSA) testing and digital rectum examination, patients with suspected prostate cancer are required to undergo prostate biopsy. However, the ability of ultrasound-guided prostate biopsy to detect prostate cancer is limited. Nowadays, a variety of diagnostic methods and more sensitive diagnostic methods, such as multi-parameter prostate magnetic resonance imaging (mpMRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) can be applied clinically. Furthermore, laparoscopic/robot-assisted prostatectomy is also a safe and effective procedure for the treatment of benign prostatic hyperplasia. So maybe it is time to reconsider the necessary to perform prostate biopsy before radical prostatectomy. AIM To explore the feasibility of radical prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques. METHODS From June 2014 to November 2018, 11 cases of laparoscopic radical prostatectomy without prostate biopsy were performed at the three tertiary medical centers involved in this study. All patients received prostate magnetic resonance imaging and prostate cancer was suspected, including six patients with positive 68Ga- PSMA PET/CT results. Laparoscopic radical prostatectomy and pelvic lymph node dissection were performed for all patients. RESULTS All surgeries were accomplished successfully. The mean age was 69 ± 7.7 year, the mean body mass index was 24.7 ± 1.6 kg/m2, the range of serum PSA was 4.3 to >1000 ng/mL, and the mean prostate volume was 40.9 ± 18.3 mL. The mean operative time was 96 ± 23.3 min, the mean estimated blood loss was 90 ± 90.9 mL, and the median duration of catheter placement was 14 d. The final pathology confirmed that all specimens were prostate cancer except one case of benign prostatic hyperplasia. No major complications occurred in 90 d postoperatively. CONCLUSION The current practice of mandating a prostatic biopsy before prostatectomy should be reconsidered in the era of new imaging technology and minimally invasive techniques. Radical prostatectomy could be carried out without the evidence of malignancy. Large-sample randomized controlled trials are definitely required to confirm the feasibility of this new concept.

Transrectal versus transperineal prostate biopsy for cancer detection in patients with gray-zone prostatespecific antigen:a multicenter,real-world study

Knowledge about the effect of different prostate biopsy approaches on the prostate cancer detection rate(CDR)in patients with gray-zone prostate-specific antigen(PSA)is limited.We performed this study to compare the CDR among patients who underwent different biopsy approaches and had rising PSA levels in the gray zone.Two hundred and twenty-two patients who underwent transrectal prostate biopsy(TRB)and 216 patients who underwent transperineal prostate biopsy(TPB)between June 2016 and September 2022 were reviewed in this study.In addition,110 patients who received additional targeted biopsies following the systematic TPB were identified.Clinical parameters,including age,PSA derivative,prostate volume(PV),and needle core count,were recorded.The data were fitted via propensity score matching(PSM),adjusting for potential confounders.TPB outperformed TRB in terms of the CDR(49.6%vs 28.3%,P=0.001).The clinically significant prostate cancer(csPCa)detection rate was not significantly different between TPB and TRB(78.6%vs 68.8%,P=0.306).In stratified analysis,TPB outperformed TRB in CDR when the age of patients was 65–75 years(59.0%vs 22.0%,P<0.001),when PV was 25.00–50.00 ml(63.2%vs 28.3%,P<0.001),and when needle core count was no more than 12(58.5%vs 31.5%,P=0.005).The CDR(P=0.712)and detection rate of csPCa(P=0.993)did not significantly differ among the systematic,targeted,and combined biopsies.TPB outperformed TRB in CDR for patients with gray-zone PSA.Moreover,performing target biopsy after systematic TPB provided no additional benefits in CDR.

Cost-effectiveness analysis of different anesthesia strategies for transperineal MRI/US fusion prostate biopsy

This study aims to conduct a cost-effectiveness analysis of three different anesthesia strategies,namely chatting while under local anesthesia(Chat-LA),total intravenous anesthesia(TIVA),and general anesthesia with laryngeal mask airway(GA-LMA),employed in transperineal magnetic resonance imaging(MRI)/ultrasound(US)fusion prostate biopsy(TP-MUF-PB).A retrospective study was conducted involving 1202 patients who underwent TP-MUF-PB from June 2016 to April 2023 at The First Affiliated Hospital of Soochow University(Suzhou,China).Clinical data and outcomes,including total costs,complications,and quality-adjusted life years(QALYs),were compared.Probability sensitivity and subgroup analyses were also performed.Chat-LA was found to be the most cost-effective option,outperforming both TIVA and GA-LMA.However,subgroup analyses revealed that in younger patients(under 65 years old)and those with smaller prostate volumes(<40 ml),TIVA emerged as a more cost-effective strategy.While Chat-LA may generally be the most cost-effective and safer anesthesia method for TP-MUF-PB,personalization of anesthesia strategies is crucial,considering specific patient demographics such as age and prostate volume.

Three-dimensional printing technique assisted cognitive fusion in targeted prostate biopsy

Objective:To explore the effect of 3-dimensional(3D)printing-assisted cognitive fusion on improvement of the positive rate in prostate biopsy.Methods:From August to December 2014,16 patients with suspected prostatic lesions detected by multiparametric magnetic resonance imaging(MRI)were included.Targeted prostate biopsy was performed with the use of prostate 3D reconstruction modeling,computersimulated biopsy,3D printing,and cognitive fusion biopsy.All patients had received 3.0 T multiparametric MRI before biopsy.The DICOM MRI files were imported to medical imaging processing software for 3D reconstruction modeling to generate a printable.stl file for 3D printing with use of transparent resin as raw material.We further performed a targeted 2-to 3-core biopsy at suspected lesions spotted on MRI.Results:For the 16 patients in the present study,3D modeling with cognitive fusion-based targeted biopsy was successfully performed.For a single patient,1e2 lesions(average:1.1 lesions)were discovered,followed by 2-6 cores(average:2.4 cores)added as targeted biopsy.Systematic biopsies accounted for 192 cores in total,with a positive rate of 22.4%;targeted biopsies accounted for 39 cores in total,with a positive rate of 46.2%.Among these cases,10 patients(62.5%)were diagnosed with prostate adenocarcinoma,in which seven were discovered by both systematic and targeted biopsy,one was diagnosed by systematic biopsy only,and two were diagnosed by targeted biopsy only.For systematic biopsy,Gleason score ranged from 6 to 8(average:7),while that for targeted biopsy ranged from 6 to 9(average:7.67).Among the seven patients that were diagnosed by both systematic and targeted biopsy,three(42.8%)were reported with a higher Gleason score in targeted therapy than in systematic biopsy.Conclusion:3D printing-assisted cognitive fusion technique markedly promoted positive rate in prostate biopsy,and reduced missed detection in high-risk prostate cancer.

The optimal timing of post-prostate biopsy magnetic resonance imaging to guide nerve-sparing surgery

The goal of our study was to evaluate the impact of the interval between prostate biopsy and magnetic resonance imaging （MRI） on the accuracy of simple tumor localization, which is essential information that enables nerve-sparing surgery. We also sought to determine the optimal timing of a post-biopsy MRI, A total of 184 patients who had undergone MRI before radical prostatectomy at an institution without a predetermined schedule for MRI after a prostate biopsy were enrolled. The mean interval from the biopsy to the MRI was 30.8 ± 18.6days. The accuracy of the MRI for simplified tumor location （right, left, bilateral and none） was 44.6%. In the group with discordant pathologic and MRI findings, the most common reason recorded was ＇MRI predicted a unilateral lesion, but pathology revealed bilateral lesions＇ （58.3%）, followed by ＇MRI predicted no lesion, but pathology revealed the presence of a lesion＇ （32.0%）. Multivariable analysis showed that the discordant group had a shorter interval （25.0 ± 14.3 vs 38.1 ± 20.6days, P 〈 0.01） preceding the MRI and a higher rate of hemorrhage as observed by MRI （80.4% vs 54.8%, P 〈 0.01） in comparison with the accordant group. In receiver operating characteristics analysis, the area under the curve of the MRI interval in accurate prediction of the tumor location was 0.707 （P 〈 0.001）. At the MRI interval＇s cutoff of 28.5days, the sensitivity was 73.2% and the specificity was 63.7%. When the MRI was performed within 28days, the accumulated accuracy was only 26.1% （23/88）; however, when it was performed after 28days, the reversely accumulated accuracy was 61.5% （59/96）. These data support a waiting period of at least 4weeks after a biopsy before performing an MRI for the purposes of surgical refinement.

Contemporary outcomes in the detection of prostate cancer using transrectal ultrasound-guided 12-core biopsy in Singaporean men with elevated prostate specific antigen and/or abnormal digital rectal examination

Objective:Despite being the third commonest cancer in Singaporean men,there is a dearth of basic data on the detection rate of prostate cancer and post-procedure complication rates locally using systematic 12-core biopsy.Our objective is to evaluate prostate cancer detection rates using 12-core prostate biopsy based on serum prostate specific antigen(PSA)levels and digital rectal examination(DRE)findings in Singaporean men presenting to a single tertiary centre.The secondary objective is to evaluate the complication rates of transrectal prostate biopsies.Methods:We retrospectively examined 804 men who underwent first transrectal-ultrasound(TRUS)guided 12-core prostate biopsies from January 2012 to April 2014.Prostate biopsies were performed on men presenting to a tertiary institution when their PSA levels were
4.0 ng/mL and/or when they had suspicious DRE findings.Results:Overall prostate cancer detection rate was 35.1%.Regardless of DRE findings,patients were divided into four subgroups based on their serum PSA levels:0e3.99 ng/mL,4.00 e9.99 ng/mL,10.00e19.99 ng/mL and
20.00 ng/mL and their detection rates were 9.5%,20.9%,38.4% and 72.3%,respectively.The detection rate of cancer based on suspicious DRE findings alone was 59.2% compared to 36.5% based on serum PSA cut-off of 4.0 ng/mL alone.The post-biopsy admission rate for sepsis was 1.5%.Conclusion:In conclusion,using contemporary 12-core biopsy methods,the local prostate cancer detection rate based on serum PSA and DRE findings has increased over the past decade presumably due to multiple genetic and environmental factors.Post-biopsy sepsis remains an important complication worldwide.

Development of a nomogram for predicting a positive repeat prostate biopsy

AIM: To fi nd risk factors of cancer in patients who had a repeat biopsy and to develop the nomogram using our cohort. METHODS: Among 3500 patients who had a prostate biopsy over 11 years between 2000 and 2010 at our hospital, we studied a total of 807 repeat biopsy sessions in 459 patients who had at least 1 initial negative biopsy. At each biopsy session, we recorded patient age, number of previous biopsy sessions, number of biopsy cores, number of previously negative biopsy cores, months from the initial biopsy, months from the previous biopsy, serum PSA, PSA slope, digital rectal examination fi ndings, hypoechoic lesions suspicious for a cancer on transrectal ultrasonography, total prostate volume, transitional zone(TZ) volume, PSA density, PSA TZ density and history of high grade prostatic intraepithelial neoplasia(HGPIN) or atypical small acinar proliferation(ASAP). Clinical and pathological variables were correlated with the outcome of repeat biopsies. A nomogram was developed based on logistic regression analyses and calibration was performed.RESULTS: Overall, 17% of repeat biopsies had a cancer. With receiver operating characteristics analyses, the highest area under the curve(AUC) was obtained based on all available 13 variables, which were age, PSA, digital rectal examination, PSA density, prostate volume, TZ volume, PSA TZ density, cumulative number of biopsy cores, HGPIN, ASAP, months from previous negative biopsy, initial negative biopsy and number of biopsy cores. Based on multivariable logistic regression analysis, a nomogram was constructed with an AUC of 0.74, which was greater than that of any single risk factor. The calibration plot seemed to be good.CONCLUSION: Our nomogram for predicting a positive repeat biopsy can provide probabilities for cancer and may help clinical judgment on whether to do a repeat prostate biopsy.

Individualized prostate biopsy strategy for Chinese patients with different prostate-specific antigen levels

Aim： To evaluate the best individualized prostate biopsy strategies for Chinese patients with suspected prostate cancer. Methods： The present study included 221 Chinese patients who underwent transrectal ultrasound guided prostate biopsies for the first time. All patients underwent the same 10-core biopsy protocol. In addition to the Hodge sextant technique, four more biopsies were obtained from the base and middle regions of bilateral peripheral zones. The differences between 10-core and sextant strategies in cancer detection among patients with different prostate specific anitgen （PSA） levels were evaluated. The relationship between PSA level, number of positive biopsy cores and organ-confined cancer rate in prostate cancer patients was also analyzed. Results： The overall prostate cancer detection rate was 40.7% in the 221 patients. The 10-core strategy increased cancer detection by 6.67% （6/90） in our patients （P 〈 0.05）. The increased cancer detection rates decreased significantly when the patient PSA level increased from 0-20 ng/mL to 20.1-50 ng/mL and 〉 50 ng/mL （P 〈 0.01）. The number of positive biopsy cores in prostate cancer patients increased significantly with increasing patient PSA level （P 〈 0.01）. The rate of organ-confined prostate cancer decreased significantly with increasing patient PSA level （P 〈 0.01）. Conclusion： The extended 10- core strategy is recommended for Chinese patients with PSA 〈 20 ng/mL and the sextant strategy is recommended for those with PSA〉 50 ng/mL. For patients with PSA ranging from 20.1 ng/mL to 50 ng/mL, the 10-core strategy should be applied in patients with life expectancy 〉 10 years and the sextant strategy should be applied in those with life expectancy 〈 10 years. （Asian J Androl 2008 Mar; 10： 325-331）

The PCA3 test for guiding repeat biopsy of prostate cancer and its cut-off score： a systematic review and meta-analysis

The specificity of prostate-specific antigen （PSA） for early intervention in repeat biopsy is unsatisfactory. Prostate cancer antigen 3 （PCA3） may be more accurate in outcome prediction than other methods for the early detection of prostate cancer （PCa）. However, the results were inconsistent in repeated biopsies. Therefore, we performed a systematic review and meta-analysis to evaluate the role of PCA3 in outcome prediction. A systematic bibliographic search was conducted for articles published before April 2013, using PubMed, Medline, Web of Science, Embase and other databases from health technology assessment agencies. The quality of the studies was assessed on the basis of QUADAS criteria. Eleven studies of diagnostic tests with moderate to high quality were selected. A meta-analysis was carried out to synthesize the results. The results of the meta-analyses were heterogeneous among studies. We performed a subgroup analysis （with or without inclusion of high-grade prostatic intraepithelial neoplasia （HGPIN） and atypical small acinar proliferation （ASAP））. Using a PCA3 cutoff of 20 or 35, in the two sub-groups, the global sensitivity values were 0.93 or 0.80 and 0.79 or 0.75, specificities were 0.65 or 0.44 and 0.78 or 0.70, positive likelihood ratios were 1.86 or 1.58 and 2.49 or 1.78, negative likelihood ratios were 0.81 or 0.43 and 0.91 or 0.82 and diagnostic odd ratios （ORs） were 5.73 or 3.45 and 7.13 or 4.11, respectively. The areas under the curve （AUCs） of the summary receiver operating characteristic curve were 0.85 or 0.72 and 0.81 or 0.69, respectively. PCA3 can be used for repeat biopsy of the prostate to improve accuracy of PCa detection. Unnecessary biopsies can be avoided by using a PCa cutoff score of 20.