Is the systematic prostate biopsy mandatory? How should lesion-based biopsy optimization be performed?

Prostate biopsy is the gold standard for diagnosing prostate cancer (PCa). Recent studies suggest that necessity and contribution of systematic biopsy (SB) in prostate biopsies are decreasing. The European Association of Urology has updated its guidelines, replacing the recommendation of targeted biopsy (TB) + SB with TB + Regional Biopsy (RB). This study aims to compare the PCa detection rates of TB, TB + RB, and TB + SB combinations. In PIRADS 3 and 5 lesions, TB alone had statistically similar diagnostic performance to the TB + SB in detecting ISUP GG ≥2 PCa (p=0.063 and p=0.5). In the PIRADS 4 group, TB's sensitivity was 80.5% (p<0.001). In 23 PIRADS 4 patients, ISUP GG ≥2 PCa cases were detected by SB but not by TB in the PIRADS 4 group. The lesion size was smaller in the group where SB contributed (7.15 mm vs. 9.88 mm, p<0.001). ROC analysis determined a cut-off value of 9.25 mm. In lesions <9.25 mm, ISUP GG ≥2 PCa was detected in 59 patients, with TB detecting 39 of these (66.1%) (p<0.001). TB + RB detected 56/59 (94.9%) ISUP GG ≥2 PCa in <9.25 mm lesions (p=0.125). In PIRADS 4 lesions ≥9.25 mm, ISUP GG ≥2 PCa was detected in 59 patients, with TB detecting 56 of these (94.9%) (p=0.25). Our results indicate that the current recommendation of TB + RB may not be mandatory for all patients. The biopsy strategy can be optimized based on the PIRADS score, location, and size of the lesion.