Modern Imaging and the Future of Prostate Biopsy: Rethinking Systematic Sampling

Prostate biopsy has shifted from systematic, non-targeted sampling towards imaging-directed approaches, but the extent to which systematic cores can be safely reduced remains uncertain. This review examines current evidence on contemporary biopsy strategies in men with suspected prostate cancer. A structured PubMed/MEDLINE search through July 2026 identified studies evaluating multiparametric magnetic resonance imaging (mpMRI), MRI-targeted biopsy, perilesional, regional and ipsilateral sampling, micro-ultrasound, prostate-specific membrane antigen positron emission tomography (PSMA PET), radiomics, and artificial intelligence. MRI-targeted biopsy improves the detection of clinically significant disease and reduces low-grade cancer diagnosis, yet targeted sampling alone may miss or undergrade clinically important tumours. Available evidence suggests that perilesional, regional, or ipsilateral sampling can preserve much of the diagnostic contribution of systematic biopsy while reducing unnecessary cores, although the evidence remains heterogeneous and is frequently retrospective. Micro-ultrasound and PSMA PET may further refine lesion localisation, while artificial intelligence may support risk assessment and biopsy planning. Current evidence supports selective reduction in systematic sampling, not its universal omission. Future biopsy strategies should integrate clinical risk, imaging quality, lesion characteristics, and targeting confidence and require prospective multicentre validation before broad implementation.