The role of transperineal template prostate biopsies in prostate cancer diagnosis in biopsy naïve men with PSA less than 20 ng ml(-1.)

Transperineal Prostate Biopsy Is the New Black: What Are the Next Targets?

Transperineal biopsy is recommended as the first-choice technique for diagnosis of prostate cancer owing to lower rates of postprocedural sepsis. However, unresolved issues such as biopsy quality, lack of a systematic biopsy template, cost-effectiveness, and the risk of acute urine retention are yet to be resolved by the urological community.

Biopsia de próstata, acceso transperineal bajo anestesia local

Objetivo La biopsia de próstata es una ayuda esencial en el diagnóstico de cáncer, siendo el método más utilizado la biopsia transrectal guiada por ultrasonido (TRUS), con una tasa diagnóstica entre el 37% y el 45%, aunque no exenta de complicaciones como infecciones, dolor o sangrado.

El enfoque alternativo y seguro a las biopsias TRUS se encuentra en la biopsia transperineal (BTP), realizada comúnmente bajo anestesia regional o general.

El objetivo de este estudio fue determinar la efectividad de la BTP bajo anestesia local y guía ultrasonográfica transrectal, con el impacto sobre la sensibilidad del estudio y la tasa de readmisión hospitalaria por infección.

Métodos Estudio de cohorte retrospectiva en el que se evaluaron 83 pacientes sometidos a BTP con anestesia local y guía ultrasonográfica transrectal de enero de 2017 a agosto de 2018 en una ciudad intermedia de Colombia. La muestea incluyó todos los hombres mayores de 18 años con datos de historia clínica disponibles para su análisis, así como los reportes histopatológicos de las biopsias. Se excluyeron casos de rebiopsia o con datos insuficientes.

El análisis de datos nominales se realizó mediante la prueba de chi cuadrado, y el de los datos numéricos, con las prubas t de Student o de Mann-Whitney.

Resultados Un total de 83 pacientes, con media de edad de 65 ± 7.9 años fueron sometidos al análisis del estudio histopatológico. Se excluyeron nueve pacientes que no tenían información disponible en el registro clínico sistematizado, ni en historia clínica de formato físico. Se encontró una proporción de positividad y diagnóstico de cáncer de prostata en el 39.7% (33) de los pacientes, distribuidos así: grado de grupo 1 (69.7%; 23); grado de grupo 2 )15.2%; 5); grados de grupos 3 y 4 (3% cada uno de ellos; 2); y grado de grupo 5 (9%; 3). En total, 60% (50) fueron negativos para malignidad y, de estos el 54% (27) tuvo hiperplasia. El antibiótico profiláctico indicado en el 96.7% (80) de los casos fue una cefalosporina de primera generación, administrada en el 15% (12) por vía parenteral preoperatoria. En esta serie de casos, no se documentaron ingresos hospitalarios asociados a infección después del procedimiento.

Conclusiones La biopsia de próstata por vía transperineal es una técnica con rendimiento diagnostico similar al del abordaje transrectal: es segura, rápida, de fácil acceso, con bajo costo y, sobre todo, con un riesgo insignificante de infección y sepsis. Sus beneficios son altamente representativos en un sistema de salud como el de nuestro país, y la BTP facilita el acceso de la población vulnerable del área rural y de ciudades intermedias, en las que no se dispone de un urólogo experto.

Prostate Cancer: Early Detection and Assessing Clinical Risk Using Deep Machine Learning of High Dimensional Peripheral Blood Flow Cytometric Phenotyping Data

Detecting the presence of prostate cancer (PCa) and distinguishing low- or intermediate-risk disease from high-risk disease early, and without the need for potentially unnecessary invasive biopsies remains a significant clinical challenge. The aim of this study is to determine whether the T and B cell phenotypic features which we have previously identified as being able to distinguish between benign prostate disease and PCa in asymptomatic men having Prostate-Specific Antigen (PSA) levels < 20 ng/ml can also be used to detect the presence and clinical risk of PCa in a larger cohort of patients whose PSA levels ranged between 3 and 2617 ng/ml. The peripheral blood of 130 asymptomatic men having elevated Prostate-Specific Antigen (PSA) levels was immune profiled using multiparametric whole blood flow cytometry. Of these men, 42 were subsequently diagnosed as having benign prostate disease and 88 as having PCa on biopsy-based evidence. We built a bidirectional Long Short-Term Memory Deep Neural Network (biLSTM) model for detecting the presence of PCa in men which combined the previously-identified phenotypic features (CD8⁺CD45RA^-CD27^-CD28^- (CD8⁺ Effector Memory cells), CD4⁺CD45RA^-CD27^-CD28^- (CD4⁺ Effector Memory cells), CD4⁺CD45RA⁺CD27^-CD28^- (CD4⁺ Terminally Differentiated Effector Memory Cells re-expressing CD45RA), CD3^-CD19⁺ (B cells), CD3⁺CD56⁺CD8⁺CD4⁺ (NKT cells) with Age. The performance of the PCa presence ‘detection’ model was: Acc: 86.79 ( ± 0.10), Sensitivity: 82.78% (± 0.15); Specificity: 95.83% (± 0.11) on the test set (test set that was not used during training and validation); AUC: 89.31% (± 0.07), ORP-FPR: 7.50% (± 0.20), ORP-TPR: 84.44% (± 0.14). A second biLSTM ‘risk’ model combined the immunophenotypic features with PSA to predict whether a patient with PCa has high-risk disease (defined by the D’Amico Risk Classification) achieved the following: Acc: 94.90% (± 6.29), Sensitivity: 92% (± 21.39); Specificity: 96.11 (± 0.00); AUC: 94.06% (± 10.69), ORP-FPR: 3.89% (± 0.00), ORP-TPR: 92% (± 21.39). The ORP-FPR for predicting the presence of PCa when combining FC+PSA was lower than that of PSA alone. This study demonstrates that AI approaches based on peripheral blood phenotyping profiles can distinguish between benign prostate disease and PCa and predict clinical risk in asymptomatic men having elevated PSA levels.

Magnetic Resonance Imaging (MRI)-Targeted Biopsy in Patients with Prostate-Specific Antigen (PSA) Levels <20 ng/mL: A Single-Center Study in Northeastern China

Background

We investigated the feasibility of applying magnetic resonance imaging (MRI)-targeted biopsy (TB) in patients with prostate-specific antigen (PSA) levels <20 ng/mL.

Material/Methods

We retrospectively analyzed 218 patients with PSA levels <20 ng/mL and suspicious lesions according to the Prostate Imaging Recording and Data System version 2.0 (PI-RADS v2). All 218 men underwent transperineal MRI-TB, followed by template-guided 12-core systematic biopsy (SB). Of the 218 patients undergoing TB, 100 received MRI-ultrasound-assisted software fusion biopsy (FB) and 118 received cognitive biopsy (CB). Clinically significant prostate cancer (csPCa) was defined as a Gleason score ≥3+4.

Results

The overall TB positive rate was similar to that of SB (P=0.156), but with a higher diagnostic rate for csPCa (P=0.034). SB misdiagnosed csPCa in 11.47% of cases; TB misdiagnosed csPCa in 5.50% of cases. SB+TB detected more tumors with a Gleason score of 7 than did SB alone (43 vs 22). Detection rates of csPCa were similar for CB and FB (P=0.217). In total, 47 men had 2 MRI-determined suspicious areas. Of 265 suspicious areas, 143 (53.96%) had a PI-RADS v2 score of 3; 92 (34.71%) had a score of 4; and 30 (11.32%) had a score of 5. The positive detection rates for csPCa in patients with PI-RADS v2 scores of 3, 4, and 5, were 11.19%, 48.91%, and 80.00%, respectively.

Conclusions

TB increased the positive biopsy detection rate but missed some cases of csPCa. TB combined with SB may be the most suitable biopsy for patients with PSA <20 ng/mL.

MRI Screening and MRI/US Fusion-Guided Transperineal Biopsy in Detecting Prostate Cancer

OBJECTIVE

Systematic biopsy plays a vital role in diagnosing prostate cancer, but it can lead to misdiagnoses or undertreatment. Advances in magnetic resonance imaging (MRI) and its guided targeting technology provide the possibility of improving the use of biopsies. This study aimed to evaluate the performance of MRI screening and MRI/ultrasound (MRI/US) fusion-guided transperineal biopsy in the detection of prostate cancer.

METHODS

We performed a retrospective study on patients with suspected prostate cancer in the Kunshan Hospital Affiliated with Jiangsu University from January 2017 to December 2019. All of the patients underwent MRI examinations, followed by a systematic biopsy (either alone or in combination with MRI/US fusion-guided targeted biopsy, based on MRI-visible lesions). We evaluated the diagnostic accuracy of MRI screening and compared biopsy methods by considering sensitivity, specificity, and area under the curve (AUC) values.

RESULTS

A total of 157 patients were enrolled, including 112 patients with MRI-visible lesions and 45 patients without MRI-visible lesions. The cancer detection rate (CDR) was higher in patients with MRI-visible lesions (P < 0.001); however, the serum prostate-specific antigen (PSA) indicators were similar (P > 0.05). The AUC of MRI was 0.63, which was superior to the AUC values of ultrasound (AUC = 0.55, P = 0.031) and digital rectal examination (AUC = 0.52, P = 0.041) for screening prostate cancer. Both overall CDR and clinically significant prostate cancer detection rates were improved if we combined systematic biopsy and MRI/US fusion-guided targeted biopsy procedures.

CONCLUSION

Overall, prior MRI screening may serve as a classifier for avoiding the overuse of biopsies. A combination of systematic and MRI/US fusion-guided targeted biopsy procedures offers an optimal regimen for detecting prostate cancer.

Identifying prostate cancer and its clinical risk in asymptomatic men using machine learning of high dimensional peripheral blood flow cytometric natural killer cell subset phenotyping data

We demonstrate that prostate cancer can be identified by flow cytometric profiling of blood immune cell subsets. Herein, we profiled natural killer (NK) cell subsets in the blood of 72 asymptomatic men with Prostate-Specific Antigen (PSA) levels < 20 ng ml^-1, of whom 31 had benign disease (no cancer) and 41 had prostate cancer. Statistical and computational methods identified a panel of eight phenotypic features ([Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text]) that, when incorporated into an Ensemble machine learning prediction model, distinguished between the presence of benign prostate disease and prostate cancer. The machine learning model was then adapted to predict the D'Amico Risk Classification using data from 54 patients with prostate cancer and was shown to accurately differentiate between the presence of low-/intermediate-risk disease and high-risk disease without the need for additional clinical data. This simple blood test has the potential to transform prostate cancer diagnostics.

Prostate MRI, with or without MRI-targeted biopsy, and systematic biopsy for detecting prostate cancer

BACKGROUND

Multiparametric magnetic resonance imaging (MRI), with or without MRI-targeted biopsy, is an alternative test to systematic transrectal ultrasonography-guided biopsy in men suspected of having prostate cancer. At present, evidence on which test to use is insufficient to inform detailed evidence-based decision-making.

OBJECTIVES

To determine the diagnostic accuracy of the index tests MRI only, MRI-targeted biopsy, the MRI pathway (MRI with or without MRI-targeted biopsy) and systematic biopsy as compared to template-guided biopsy as the reference standard in detecting clinically significant prostate cancer as the target condition, defined as International Society of Urological Pathology (ISUP) grade 2 or higher. Secondary target conditions were the detection of grade 1 and grade 3 or higher-grade prostate cancer, and a potential change in the number of biopsy procedures.

SEARCH METHODS

We performed a comprehensive systematic literature search up to 31 July 2018. We searched CENTRAL, MEDLINE, Embase, eight other databases and one trials register.

SELECTION CRITERIA

We considered for inclusion any cross-sectional study if it investigated one or more index tests verified by the reference standard, or if it investigated the agreement between the MRI pathway and systematic biopsy, both performed in the same men. We included only studies on men who were biopsy naïve or who previously had a negative biopsy (or a mix of both). Studies involving MRI had to report on both MRI-positive and MRI-negative men. All studies had to report on the primary target condition.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed the risk of bias using the QUADAS-2 tool. To estimate test accuracy, we calculated sensitivity and specificity using the bivariate model. To estimate agreement between the MRI pathway and systematic biopsy, we synthesised detection ratios by performing random-effects meta-analyses. To estimate the proportions of participants with prostate cancer detected by only one of the index tests, we used random-effects multinomial or binary logistic regression models. For the main comparisions, we assessed the certainty of evidence using GRADE.

MAIN RESULTS

The test accuracy analyses included 18 studies overall.MRI compared to template-guided biopsy: Based on a pooled sensitivity of 0.91 (95% confidence interval (CI): 0.83 to 0.95; 12 studies; low certainty of evidence) and a pooled specificity of 0.37 (95% CI: 0.29 to 0.46; 12 studies; low certainty of evidence) using a baseline prevalence of 30%, MRI may result in 273 (95% CI: 249 to 285) true positives, 441 false positives (95% CI: 378 to 497), 259 true negatives (95% CI: 203 to 322) and 27 (95% CI: 15 to 51) false negatives per 1000 men. We downgraded the certainty of evidence for study limitations and inconsistency.MRI-targeted biopsy compared to template-guided biopsy: Based on a pooled sensitivity of 0.80 (95% CI: 0.69 to 0.87; 8 studies; low certainty of evidence) and a pooled specificity of 0.94 (95% CI: 0.90 to 0.97; 8 studies; low certainty of evidence) using a baseline prevalence of 30%, MRI-targeted biopsy may result in 240 (95% CI: 207 to 261) true positives, 42 (95% CI: 21 to 70) false positives, 658 (95% CI: 630 to 679) true negatives and 60 (95% CI: 39 to 93) false negatives per 1000 men. We downgraded the certainty of evidence for study limitations and inconsistency.The MRI pathway compared to template-guided biopsy: Based on a pooled sensitivity of 0.72 (95% CI: 0.60 to 0.82; 8 studies; low certainty of evidence) and a pooled specificity of 0.96 (95% CI: 0.94 to 0.98; 8 studies; low certainty of evidence) using a baseline prevalence of 30%, the MRI pathway may result in 216 (95% CI: 180 to 246) true positives, 28 (95% CI: 14 to 42) false positives, 672 (95% CI: 658 to 686) true negatives and 84 (95% CI: 54 to 120) false negatives per 1000 men. We downgraded the certainty of evidence for study limitations, inconsistency and imprecision.Systemic biopsy compared to template-guided biopsy: Based on a pooled sensitivity of 0.63 (95% CI: 0.19 to 0.93; 4 studies; low certainty of evidence) and a pooled specificity of 1.00 (95% CI: 0.91 to 1.00; 4 studies; low certainty of evidence) using a baseline prevalence of 30%, systematic biopsy may result in 189 (95% CI: 57 to 279) true positives, 0 (95% CI: 0 to 63) false positives, 700 (95% CI: 637 to 700) true negatives and 111 (95% CI: 21 to 243) false negatives per 1000 men. We downgraded the certainty of evidence for study limitations and inconsistency.Agreement analyses: In a mixed population of both biopsy-naïve and prior-negative biopsy men comparing the MRI pathway to systematic biopsy, we found a pooled detection ratio of 1.12 (95% CI: 1.02 to 1.23; 25 studies). We found pooled detection ratios of 1.44 (95% CI 1.19 to 1.75; 10 studies) in prior-negative biopsy men and 1.05 (95% CI: 0.95 to 1.16; 20 studies) in biopsy-naïve men.

AUTHORS' CONCLUSIONS

Among the diagnostic strategies considered, the MRI pathway has the most favourable diagnostic accuracy in clinically significant prostate cancer detection. Compared to systematic biopsy, it increases the number of significant cancer detected while reducing the number of insignificant cancer diagnosed. The certainty in our findings was reduced by study limitations, specifically issues surrounding selection bias, as well as inconsistency. Based on these findings, further improvement of prostate cancer diagnostic pathways should be pursued.

Identifying the Presence of Prostate Cancer in Individuals with PSA Levels <20 ng ml-1 Using Computational Data Extraction Analysis of High Dimensional Peripheral Blood Flow Cytometric Phenotyping Data

Determining whether an asymptomatic individual with Prostate-Specific Antigen (PSA) levels below 20 ng ml⁻¹ has prostate cancer in the absence of definitive, biopsy-based evidence continues to present a significant challenge to clinicians who must decide whether such individuals with low PSA values have prostate cancer. Herein, we present an advanced computational data extraction approach which can identify the presence of prostate cancer in men with PSA levels <20 ng ml⁻¹ on the basis of peripheral blood immune cell profiles that have been generated using multi-parameter flow cytometry. Statistical analysis of immune phenotyping datasets relating to the presence and prevalence of key leukocyte populations in the peripheral blood, as generated from individuals undergoing routine tests for prostate cancer (including tissue biopsy) using multi-parametric flow cytometric analysis, was unable to identify significant relationships between leukocyte population profiles and the presence of benign disease (no prostate cancer) or prostate cancer. By contrast, a Genetic Algorithm computational approach identified a subset of five flow cytometry features (CD8⁺CD45RA⁻CD27⁻CD28⁻ (CD8⁺ Effector Memory cells); CD4⁺CD45RA⁻CD27⁻CD28⁻ (CD4⁺ Terminally Differentiated Effector Memory Cells re-expressing CD45RA); CD3⁻CD19⁺ (B cells); CD3⁺CD56⁺CD8⁺CD4⁺ (NKT cells)) from a set of twenty features, which could potentially discriminate between benign disease and prostate cancer. These features were used to construct a prostate cancer prediction model using the k-Nearest-Neighbor classification algorithm. The proposed model, which takes as input the set of flow cytometry features, outperformed the predictive model which takes PSA values as input. Specifically, the flow cytometry-based model achieved Accuracy = 83.33%, AUC = 83.40%, and optimal ROC points of FPR = 16.13%, TPR = 82.93%, whereas the PSA-based model achieved Accuracy = 77.78%, AUC = 76.95%, and optimal ROC points of FPR = 29.03%, TPR = 82.93%. Combining PSA and flow cytometry predictors achieved Accuracy = 79.17%, AUC = 78.17% and optimal ROC points of FPR = 29.03%, TPR = 85.37%. The results demonstrate the value of computational intelligence-based approaches for interrogating immunophenotyping datasets and that combining peripheral blood phenotypic profiling with PSA levels improves diagnostic accuracy compared to using PSA test alone. These studies also demonstrate that the presence of cancer is reflected in changes in the peripheral blood immune phenotype profile which can be identified using computational analysis and interpretation of complex flow cytometry datasets.

The predictive efficacy of hypoechoic lesion in ultrasound for prostate cancer in Chinese people: five-year experience in a moderated 10-core transperineal prostate biopsy procedure

We aim to investigate the predictive efficacy of hypoechoic lesion for prostate cancer at different levels of serum PSA in the procedure of transrectal ultrasound guided 10-core trans-perineal prostate biopsy (TP-PBx). In this study, we collected clinical parameters involving age, digital rectal examination (DRE), PSA, prostate volume, pathological diagnosis, Gleason score, novel Gleason group, and numbers of positive cores from 856 patients who had elevated level of PSA above 4 ng/ml or susceptible nodule of prostate gland in DRE received the moderated 10-core TP-PBx procedure. There were 481 cases (56.2%) with no visible lesion of hypoechoic nodule in transrectal ultrasound (TRUS) and 375 cases (43.8%) with the hypoechoic lesion. The total cancer detection rate is 45.56%. The predictive efficacy of hypoechoic lesion for prostate cancer varies among different PSA intervals. For PSA groups of 0-4, 4-10, 10-20, 20-100, > 100 ng/ml, the Youden's indexes are 0.3483, 0.3506, 0.3941, 0.2795 and 0.8667, respectively. Besides, the visible lesions are inclined to be detected in patients with higher Gleason score. We concluded that the hypoechoic lesions in TRUS could improve the predictive accuracy for diagnosing prostate cancer and present different predictive efficacy in the respective PSA intervals. Besides, it was probably associated with more aggressive clinical significance.

Preliminary study on ultrasound-guided prostate biopsy specimen scores

Prostate cancer (PCa) is the second most frequently diagnosed cancer in males worldwide and resulted in ~258,000 cases of cancer-associated mortality in 2008. The present study visually determined the pathology scores of PCa specimens by taking into account five characteristics, including the hardness, color, plumpness, transparency and uniformity of specimens. The current study also aimed to identify the association between pathology scores and prostate specific antigen (PSA) levels, in order to reduce the complications caused by punctures and elevate the specimen positive rates. A total of 1,608 specimens from 268 patients were analyzed by one sonographer, one urologist and one pathologist. A standard pathological examination was performed on the PCa biopsy specimens and specimen scores were recorded under double-blinded conditions. A receiver operator characteristic curve identified a linear correlation between the visually determined score and PSA levels (r=0.255; P<0.001). Furthermore, logistic regression analysis indicated that the visually determined score and PSA were correlated with the diagnosis of PCa. Additionally, the authenticity of the visually determined score was higher than PSA in the diagnosis of PCa, with the best sensitivity and specificity of the visually determined scores used to predict PCa being 0.817 and 0.931, respectively.

Population-based study of grade progression in patients who harboured Gleason 3 + 3

PURPOSE

This study aimed to evaluate (1) the time interval between a decision to commence on active surveillance (AS) and grade progression in community practice; (2) factors predicting grade progression in localised prostate cancer (CaP) patients apparently undergoing AS.

METHODS

Data from the Prostate Cancer Outcomes Registry-Victoria were used to analyze men with Gleason 3 + 3 CaP or less who had at least one repeat biopsy. Unadjusted and adjusted 5-year Kaplan-Meier survival curves were used to assess the time to grade progression. Both univariate and multivariate analyses for grade progression were performed using Cox proportional hazards.

RESULTS

The cohort included 951 men. Overall, 39% of men had Gleason grade reclassified to a higher risk disease state with median of 2.2 years [IQR 1.2-3.7 years]. Men who harboured cT2 disease were 30% more likely to have upgrading compared to men with cT1 disease (adjusted HR: 1.3, 95% CI 1.0-1.6, p = 0.048). Half of the men with cT2 in our cohort had their Gleason grade reclassified within 1.6 years from diagnosis as compared with 2.7 years for the cT1 group. The presence of percentage of core involvement >25.0% and a PSA velocity of >1.01 ng/mL/year remained significant for a higher progression rate. The adjusted HR: 1.6; 95% CI [1.2-2.3], p = 0.004; adjusted HR: 1.6, 95% CI [1.2-2.4], p = 0.021, for percent of core involvement of 25.1-37.5%, and ≥37.6%, respectively. The adjusted HRs and p value associated with PSA velocity were 1.5; 95% CI [1.1-2.1], p = 0.016 and 1.6; 95% CI [1.2-2.3], p = 0.003 for PSA velocity values of 1.01-2 ng/mL per year and >2 ng/mL per year, respectively. Men who were diagnosed in regional hospital and subsequently had biopsy in metropolitan hospital were twice at risk of having Gleason upgrade compared to those whom both diagnostic and surveillance biopsies were carried out in metropolitan hospitals (adjusted HR: 1.9; 95% CI 1.1-3.3, p = 0.029).

CONCLUSIONS

When placing men on AS and considering time to histologic progression, clinicians should pay particular attention to the likely accuracy of the diagnostic specimen, their tumour stage, volume of tumour (percent of core involvement), and rising PSA. Those diagnosed with T2 disease and had >25.0% of core involvement, and a PSA velocity greater than 1 ng/mL per year is at particular risk for more rapid disease progression and, for this reason, should be counselled on the importance of following the recommended surveillance regimen. For half of these men, their disease will have 'progressed' according to biopsy results in 2 years.

Role of transperineal template biopsy in prostate cancer

Prostate cancer is the most common neoplasm diagnosed in men. Whilst treatment modalities have progressed, diagnostic investigations in terms of biopsy methods have been assessed but there is no consensus of when the different diagnostic methods in terms of transrectal ultrasound (TRUS) or transperineal template (TPT) should be utilised. TPT biopsy has a higher diagnostic yield than TRUS in those with a primary biopsy, in those with previous negative biopsies with TRUS as well as those undergoing saturation biopsies. Despite the increased likelihood of diagnosing cancer with TPT than TRUS this maybe secondary to the increased number of biopsies being utilised. However there is no consensus regarding the ideal number of biopsies that should be utilised with TPT. Furthermore it is felt that the increased number of biopsies utilised with TPT is associated the higher complication rates with TPT. The role of TPT biopsy is recognised in those with previous negative biopsies with transrectal ultrasound but further work is required regarding the ideal number of biopsies. Furthermore, it is felt that TPT biopsy may have a role in primary biopsy.

The role of transperineal template biopsies of the prostate in the diagnosis of prostate cancer: a review

The incidence of prostate cancer has shown a significant increase, highlighting the importance of early diagnosis. Current practice considers histological diagnosis a necessity in the majority of the cases. The limitations of transrectal biopsies led to the development of the promising transperineal prostatic biopsies. The latter offers a safer approach by avoiding the rectum, utilizing brachytherapy template grid to detect anterior zone disease and provides accurate prostatic mapping by systematically sampling the whole gland. It also helps to direct biopsies based on images obtained from previous prostate scanning and identify those eligible for focal therapy to direct focal treatment accurately. The current literature provides enough reassurance that transperineal template biopsies are effective, efficient and superior to the traditional and inaccurate transrectal biopsies. The absence of consensus on the technical aspect of template biopsies is a drawback, yet it highlights the need to develop robust guidelines to standardize the procedure.