Radical prostatectomy without prior biopsy: an initial decision-making algorithm based on PSMA PET/mpMRI

Area of Science:

• Oncology
• Radiology
• Urology

Background:

• Advancements in radiological imaging suggest potential for biopsy-free prostate cancer (PCa) diagnosis.
• Comprehensive evaluation of safety, feasibility, and accuracy is crucial for biopsy-free approaches.
• This study focuses on an algorithm for selecting patients for radical prostatectomy without prior biopsy (RP-WPB).

Purpose of the Study:

• To evaluate a novel decision-making algorithm for identifying suitable candidates for RP-WPB.
• To assess the safety, feasibility, and diagnostic accuracy of using PSMA PET/CT and mpMRI for PCa diagnosis without biopsy.
• To streamline the selection process for radical prostatectomy in specific PCa patient cohorts.

Main Methods:

• A prospective decision-making algorithm was implemented for patient enrollment.
• Key criteria included PSA levels, PI-RADS, miPSMA scores, and co-positive lesions on mpMRI and PSMA PET/CT.
• Specific staging criteria (cT3-4, cN1, cM1) and PSA stratification for cT2N0M0 patients guided RP-WPB eligibility.

Main Results:

• 120 patients underwent RP-WPB from January 2022 to February 2024, following the algorithm.
• The detection rate of clinically significant PCa (ISUP grade ≥2) was 100%.
• Pathological concordance was achieved in all cases with no perioperative complications exceeding Clavien-Dindo grade II.

Conclusions:

• The PSMA PET/CT and mpMRI-based algorithm is safe, feasible, and highly accurate for selecting PCa patients for RP-WPB.
• This approach offers a promising alternative to traditional biopsy for specific patient groups.
• The study validates the diagnostic utility of advanced imaging in guiding PCa treatment decisions.