Optimizing Prostate Biopsy Pathways: Integrating MRI-Targeted, Systematic Sampling, and Clinical Judgment in the...

Area of Science:

• Urology
• Oncology
• Radiology

Background:

• Prostate cancer diagnostics have advanced with multiparametric MRI (mpMRI), prostate-specific antigen (PSA) metrics, and targeted biopsies.
• Despite advancements, mpMRI is not infallible, potentially leading to missed clinically significant prostate cancer, especially with MRI-occult disease or abnormal PSA kinetics.

Purpose of the Study:

• To review current evidence on PSA interpretation, mpMRI performance, and biopsy strategies.
• To highlight limitations of single-parameter diagnostic approaches in prostate cancer detection.
• To propose a risk-adapted diagnostic pathway integrating multiple parameters.

Main Methods:

• This narrative review synthesizes contemporary evidence from peer-reviewed literature.
• It analyzes the diagnostic yield and clinical implications of targeted, systematic, and combined biopsy techniques.
• Expert-derived conceptual framework for risk-adapted decision-making is presented.

Main Results:

• Single-parameter approaches have limitations in detecting clinically significant prostate cancer.
• Combined targeted and systematic biopsy strategies show promise for maximizing detection and minimizing overdiagnosis.
• Systematic sampling remains crucial even with negative or equivocal imaging findings.

Conclusions:

• Integrating PSA dynamics, prostate volume, imaging, and risk profiles enables a structured, risk-adapted diagnostic pathway.
• Combined targeted and systematic biopsy is the most robust strategy for biopsy-naive and high-risk patients.
• Prospective validation of the proposed framework is warranted.