Introduction. Our aim was to assess the value of adding standard biopsy to targeted biopsy in cases of suspicious multiparametric magnetic resonance imaging (mp-MRI) and also to evaluate when a biopsy of a PI-RADS 3 lesion could be avoided. Methods: A retrospective study of patients who underwent targeted biopsy plus standard systematic biopsy between 2016–2019 was performed. All the 1.5 T magnetic resonance images were evaluated according to PI-RADSv.2. An analysis focusing on the clinical scenario, lesion location, and PI-RADS score was performed. Results. A total of 483 biopsies were evaluated. The mean age was 65 years, with a PSA density of 0.12 ng/mL/cc. One-hundred and two mp-MRIs were categorized as PI-RADS-3. Standard biopsy was most helpful in detecting clinically significant prostate cancer (csPCa) in patients in the active surveillance (AS) cohort (increasing the detection rate 12.2%), and in peripheral lesions (6.5%). Adding standard biopsy showed no increase in the detection rate for csPCa in patients with PI-RADS-5 lesions. Considering targeted biopsy in patients with PI-RADS 3 lesions, a higher detection rate was shown in biopsy-naïve patients versus AS and in patients with a previous negative biopsy (p = 0.002). Furthermore, in these patients, the highest rate of csPCa detection was in anterior lesions [42.9% (p = 0.067)]. Conclusions. Our results suggest that standard biopsy could be safely omitted in patients with anterior lesions and in those with PI-RADS-5 lesions. Targeted biopsy for PI-RADS-3 lesions would be less effective in peripheral lesions with a previous negative biopsy.

Objective: To describe a new approach to perform ultrasound-MRI-guided prostate biopsies in patients without access to the rectum. Methods: Patients with elevated prostate-specific antigen (PSA) levels and absent rectum approach to perform a traditional transrectal prostate biopsy (TPB) pose a challenge in clinical practice. In this study, we describe a useful new device to guide biopsy in patients with target lesions in a multiparametric-MRI (mpMRI) and no availability of TPB. Results: We present two different cases of patients with PSA elevation and mpMRI lesion and no possibility of TPB. They underwent a modified single-port transperineal biopsy technique using MRI coregistered images and eTRAX device-assisted, to accurately guide the biopsy to the target lesion. The target biopsy diagnosed significant prostate cancer in both cases and no complications occurred after the procedure. Conclusion: In patients with no rectum access, ultrasound MRI coregistration biopsies assisted by eTRAX device seem to be an alternative minimally invasive approach since it is effective, reproducible, and safe. No competing financial interests exist. Runtime of video: 3 mins 57 secs The initial study was presented at the 2021 American Congress of Urology in a virtual format. The abstract is available at https://www.auajournals.org/doi/pdf/10.1097/JU.0000000000002111.05 .