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Purpose: Multiparametric magnetic resonance imaging and magnetic resonance imaging targeted biopsy may improve the detection of clinically significant prostate cancer. However, standardized prospective evaluation is limited.Materials and Methods: A total of 294 consecutive men with suspicion of prostate cancer (186 primary, 108 repeat biopsies) enrolled in 2013 underwent 3T multiparametric magnetic resonance imaging (T2-weighted, diffusion weighted, dynamic contrast enhanced) without endorectal coil and systematic transperineal cores (median 24) independently of magnetic resonance imaging suspicion and magnetic resonance imaging targeted cores with software registration (median 4). The highest Gleason score from each biopsy method was compared. McNemar’s tests were used to evaluate detection rates. Predictors of Gleason score 7 or greater disease were assessed using logistic regression.Results: Overall 150 cancers and 86 Gleason score 7 or greater cancers were diagnosed. Systematic, transperineal biopsy m...

RRP radical retropubic prostatectomy, HDR high dose rate brachytherapy, Cryo cryoablation, HIFU high-intensity focused ultrasound, TURP transurethral resection of the prostate, OIU optic internal urethrotomy, SD standard deviation, IIEF-5 5-item version of the international index of erectile function, IPSS international prostate symptom score, QoL quality of life *Erectile dysfunction and Mean scores for IIEF-5 were restricted to those men who reported IIEF-5 17 at baseline Vol. 195, No. 4S, Supplement, Friday, May 6, 2016 THE JOURNAL OF UROLOGY e201

Purpose We developed an effective way to precisely diagnose prostate cancer using a novel prostate biopsy system that integrates pre-interventional magnetic resonance imaging with peri-interventional ultrasound for perineal navigated prostate biopsy. Materials and Methods A total of 106 men with findings suspicious for prostate cancer (median age 66 years, prostate specific antigen 8.0 ng/ml and prostate volume 47 ml) underwent multiparametric 3 Tesla magnetic resonance imaging. Suspicious lesions were marked and data were transferred to the novel biopsy system. Using a custom-made biplane transrectal ultrasound probe mounted on a stepper we gathered 3-dimensional ultrasound data and fused them with magnetic resonance imaging data. As a result, suspicious magnetic resonance imaging lesions were superimposed over the transrectal ultrasound data. Three-dimensional biopsy planning was done, including systematic biopsies. Perineal biopsies were taken under live ultrasound guidance and the precise site of each biopsy was documented in 3 dimensions. We evaluated feasibility, safety and cancer detection. Results Prostate cancer was detected in 63 of 106 patients (59.4%). Magnetic resonance imaging findings correlated positively with histopathology in 71 of 103 patients (68.9%). In magnetic resonance imaging lesions marked as highly suspicious, the detection rate was 95.8% (23 of 24 cases). Lesion targeted cores had a significantly higher positivity rate than nontargeted cores. The procedural targeting error of the first 2,461 biopsy cores was 1.7 mm. Regarding adverse effects, 2 patients experienced urinary retention and 1 had a perineal hematoma. Urinary tract infections did not develop. Conclusions Perineal stereotactic prostate biopsies guided by the combination of magnetic resonance imaging and ultrasound enable effective examination of suspicious magnetic resonance imaging lesions. Each biopsy core taken is documented accurately for its location in 3 dimensions, enabling magnetic resonance imaging validation and tailored treatment planning. The morbidity of the procedure was minimal.

This research was also made possible through the National Institutes of Health Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH from Pfizer Inc., The Doris Duke Charitable Foundation, The Alexandria Real Estate Equities, Inc. and Mr. and Mrs. Joel S. Marcus, and the Howard Hughes Medical Institute, as well as other private donors. For a complete list, please visit the Foundation website at: http://fnih.org/work/education-training0/medical-research-scholars-program

INTRODUCTION AND OBJECTIVES: The key challenge for focal therapy of prostate cancer is to identify index lesions. In this context, we describe our initial experience with a new stereotactic prostate biopsy system, which integrates pre-interventional MRI data with periinterventional ultrasound for perineal prostate biopsies. METHODS: 33 patients were stereotactically biopsied (mean age of 64yrs., mean PSA level of 8.2ng/ml and mean prostate vol. of 40ml). 21 of these 33 patients had already had a negative transrectal US-guided biopsy. All men underwent multimodal 3 Tesla MRI without endorectal coil including diffusion weighted imaging and dynamic contrast enhanced sequences as well as MR-spectroscopy. Suspicious lesions were marked by radiologists with over 10 years experience in reading prostate MRI before the obtained data were transferred to the stereotactic biopsy system. Using a custom-made biplane TRUS probe mounted on a stepper device, 3D ultrasound data were generated to set the anatomic landmarks. Then MRI and TRUS imaging data were fused manually. As a result, the suspicious MRI lesions were superimposed onto the TRUS data. Next, 3D biopsy planning was performed including systematic biopsies from the peripheral and transitional zones of the prostate. Perineal biopsies were taken under live US imaging, and the location of each biopsy was documented in 3D. RESULTS: 14 out of 33 patients were diagnosed with prostate cancer. These results showed a positive correlation between MRI findings and histopathology in 22 out of 33 patients. In MRI lesions marked as highly suspicious, the detection rate was 100%. Evaluating the biopsies from lesions marked as highly and as questionable suspicious together, prostate cancer was detected in 27.95%. In comparison, only 8% of the additional systematic biopsies were positive. Target registration error of the first 554 biopsy cores was 1.9 mm. For adverse effects, one patient experienced urinary retention. Postinterventional hemorrhage or urinary tract infection did not occur. CONCLUSIONS: Perineal stereotactic prostate biopsies guided by the combination of MRI and ultrasound enable effective examination of suspicious MRI lesions. Additionally, each biopsy core taken may be documented accurately for its location in 3D. Thus, MRI data may be validated and different treatment options stratified in depth. At the same time the morbidity of the procedure was minimal.