A Triple Clinical Filter Model for Selective Omission of Systematic Cores in Transperineal Cognitive Prostate Biopsy:...

To determine whether systematic biopsy can be safely omitted in selected patients undergoing antibiotic-free transperineal cognitive MRI-targeted prostate biopsy under local anesthesia, and to identify clinical and imaging parameters associated with cognitive biopsy superiority.

This retrospective study included patients who underwent antibiotic-free transperineal prostate biopsy under local anesthesia. All patients had multiparametric prostate MRI (mpMRI) visible lesions and received both systematic and cognitive MRI-targeted biopsy. Targeted cores were obtained from all PI-RADS 4-5 lesions and from PI-RADS 3 lesions only when PSA density was ≥ 0.10 ng/mL/cm³. Cognitive biopsy non-inferiority was defined as an ISUP Grade Group equal to or higher than that obtained from systematic cores in the same patients. PSA density, MRI lesion size, and PI-RADS category were incorporated into a multivariable model to predict when systematic sampling would not add diagnostic value.

The multivariable model incorporating PSA density, MRI lesion size, and PI-RADS category demonstrated good discriminatory performance (AUC 0.881, sensitivity 92.6%, specificity 84.8%). In patients meeting all predefined model criteria, cognitive biopsy achieved concordant or superior grading in 95.2% of cases, whereas in those not meeting these criteria, systematic biopsy provided higher-grade detection in all cases within this subgroup.

In carefully selected patients with elevated PSA density, larger mpMRI visible lesions, and high PI-RADS scores, transperineal cognitive MRI-targeted biopsy may support the selective omission of systematic cores without compromising diagnostic reliability. In contrast, systematic sampling remains indispensable in lower-risk profiles, underscoring the value of a risk-adapted biopsy strategy.