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Landmarks in the evolution of prostate biopsy

Nature Reviews Urology volume 20, pages 241–258 (2023)Cite this article

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Abstract

Approaches and techniques used for diagnostic prostate biopsy have undergone considerable evolution over the past few decades: from the original finger-guided techniques to the latest MRI-directed strategies, from aspiration cytology to tissue core sampling, and from transrectal to transperineal approaches. In particular, increased adoption of transperineal biopsy approaches have led to reduced infectious complications and improved antibiotic stewardship. Furthermore, as image fusion has become integral, these novel techniques could be incorporated into prostate biopsy methods in the future, enabling 3D-ultrasonography fusion reconstruction, molecular targeting based on PET imaging and autonomous robotic-assisted biopsy.

Key points

  • The techniques of prostate biopsy have undergone considerable evolution over time, from early finger-guided techniques to current MRI-targeted strategies.

  • The improvement in performance associated with pre-biopsy multiparametric MRI compared with random transrectal ultrasonography-guided biopsy sampling has led to a dramatic change in the prostate cancer diagnostic pathway.

  • Pre-biopsy multiparametric MRI has mitigated the risk of underdiagnosis of clinically significant disease and overdiagnosis of clinically insignificant disease, both of which were associated with random prostate sampling.

  • Increased adoption of transperineal rather than transrectal approaches to biopsy sampling has minimized infectious complications and improved antibiotic stewardship.

  • Novel techniques — including 3D-ultrasound fusion reconstruction, multiparametric ultrasonography, high-resolution micro-ultrasonography, molecular (positron emission) image targeting and autonomous robotic-assisted biopsy — have been integrated into prostate biopsy sampling at various stages of deployment and use.

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Fig. 1: Landmarks in the history of prostate biopsy.
Fig. 2: Historical biopsy techniques before transrectal ultrasonography invention.
Fig. 3: Transperineal MRI–transrectal ultrasound fusion biopsy.
Fig. 4: Transperineal template mapping biopsy.
Fig. 5: Combined pelvic PSMA PET–CT and multiparametric MRI prostate.

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Author notes

  1. These authors contributed equally: Martin J. Connor, Michael A. Gorin.

Authors and Affiliations

  1. Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK

    Martin J. Connor, David Eldred-Evans, Edward J. Bass, Ankit Desai, Mathias Winkler & Hashim U. Ahmed

  2. Imperial Urology, Imperial College Healthcare NHS Trust, London, UK

    Martin J. Connor, David Eldred-Evans, Edward J. Bass, Mathias Winkler & Hashim U. Ahmed

  3. Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Michael A. Gorin

  4. Department of Urology, University Hospital Southampton, Southampton, UK

    Tim Dudderidge

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Contributions

M.J.C. and D.E.-E. researched data for the article. M.J.C., D.E.-E., A.D., T.D., M.W. and H.U.A. contributed substantially to discussion of the content. M.J.C., M.A.G., D.E.-E., E.J.B., and A.D. wrote the article. M.J.C., M.A.G., D.E.-E., E.J.B., T.D., M.W. and H.U.A. reviewed and/or edited the manuscript before submission.

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Correspondence to Martin J. Connor.

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Competing interests

M.A.G. is a paid consultant for bk Medical ApS, KOELIS, and Perineologic. H.U.A. currently receives funding from Sonacare Inc., Trod Medical and Sophiris Biocorp for trials and studies in prostate cancer and is a paid medical consultant for Sophiris Biocorp, Sonacare Inc. and BTG/Galil, and a paid proctor for HIFU, cryotherapy and Rezum water vapour therapy. The other authors declare no competing interests.

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Glossary

Apparent diffusion coefficient

(ADC). ADC measures the magnitude of diffusion (of water molecules) within tissue.

Biplanar TRUS

In biplanar TRUS, a transrectal ultrasonography probe provides a longitudinal and transverse view.

Brachytherapy grid

Template grids consisting of rows and columns of holes, traditionally spaced 5 mm apart.

Brachytherapy stepper

Classic stabilizers for TRUS probes that provide six degrees of freedom of movement including X, Y and Z axis plus pitch, yaw and roll.

Cognitive-fusion

In cognitive-fusion, the operator interprets information from the patient’s MRI to target lesions during biopsy that might or might not be visible on ultrasonography.

Diffusion-weighting imaging

(DWI). DWI is a form of MR imaging based on measuring the random Brownian motion of water molecules within a voxel of tissue.

Freehand technique

For freehand biopsy, the needle is guided to the target with one hand whereas the other hand positions the ultrasonography transducer for adequate visualization.

Screw-tip

A screw-tip needle consists of a wide-bore needle that is rotated clockwise inside a sheath to activate. This motion results in tissue acquisition.

Software-fusion

In software-fusion, the operator uses software to overlay the MRI with TRUS images obtained at the time of biopsy sampling to generate a fused 3D computer model for use in real-time guidance of biopsy sampling.

Spectroscopy

Spectroscopy enables tissue to be interrogated for the presence and concentration of various metabolites identical to that of nuclear magnetic resonance.

Steady-state free precession image

A type of gradient echo MRI pulse sequence in which a steady, residual transverse magnetization (Mxy) is maintained between successive cycles.

SUVmax

A measure of the maximum standardized uptake value of a radiotracer by (malignant) tissue.

T2WI

T2-weighted images are basic pulse sequences representing the difference in the T2 relaxation time of tissues.

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Connor, M.J., Gorin, M.A., Eldred-Evans, D. et al. Landmarks in the evolution of prostate biopsy. Nat Rev Urol 20, 241–258 (2023). https://doi.org/10.1038/s41585-022-00684-0

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