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.
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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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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- 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.
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.
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.
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 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.
A measure of the maximum standardized uptake value of a radiotracer by (malignant) tissue.
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 (2023). https://doi.org/10.1038/s41585-022-00684-0