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Background: Focal treatment for prostate cancer (PCa) is a hybrid approach combining ablative treatment of the involved prostate gland and continued active surveillance (AS) of the unaffected gland. Low dose-rate (LDR) brachytherapy can be used as a lesion-targeted focal therapy, however, further studies are required to support its use. The aim of this study is to evaluate the dosimetry, toxicity and oncological outcomes of men receiving lesion-targeted focal LDR brachytherapy for low to intermediate risk PCa., Methods: This is a retrospective cohort study of 26 men with unifocal, low to intermediate grade PCa diagnosed on a combination of multiparametric-magnetic resonance imaging (mp-MRI) and targeted plus template transperineal (TP) biopsy, who received focal LDR brachytherapy at a single institution. Brachytherapy involved a single monotherapy implant using iodine-125 seeds to deliver a prescribed dose of 145 Gy to the index lesion., Results: The mean focal planning target volume (F-PTV) as a percentage of the prostate volume was 24.5%. The percentage of the focal gross tumour volume (F-GTV) receiving 100% of the prescription dose was 100% for 12 patients and ≥98% for 18 patients. The median follow-up for toxicity and biochemical control outcomes was 23.1 [interquartile range (IQR) 19.1-31.3] and 24.2 (IQR 17.9-30.0) months, respectively. Grade 2 urinary and erectile toxicities were reported by 29.2% and 45.8% of patients, respectively, with resolution of urinary symptoms to baseline by last follow-up. There were no grade ≥3 urinary or erectile toxicities or grade ≥2 rectal toxicity. All 21 patients who underwent a repeat mp-MRI and TP biopsy at 12-24 months post-treatment were negative for clinically significant disease and 25 (96.2%) patients were free from biochemical failure (FFBF)., Conclusions: Focal LDR brachytherapy is associated with a favourable toxicity profile and a high rate of control of significant PCa at 12-18 months post-treatment. We have commenced the LIBERATE prospective registry in focal LDR brachytherapy based on the highly encouraging outcomes of this initial experience., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/tau-21-508). The authors have no conflicts of interest to declare., (2021 Translational Andrology and Urology. All rights reserved.)

As the second most diagnosed cancer worldwide, prostate cancer is confirmed via tissue biopsy. Given the large number of prostate biopsies performed each year, the technique should be as accurate and safe as possible for the patient's well-being. Transrectal ultrasound guided prostate biopsy (TRUS-biopsy) is most offered worldwide. Transperineal biopsy (TPP-biopsy), on the other hand, has been gaining popularity due to its superior sensitivity and lower rate of sepsis. This article offers a review of the brachytherapy grid technique used to perform a TPP-biopsy, as well as a discussion of possible variations in the procedure. TPP-biopsy is typically performed under general anaesthesia with patient in lithotomy. Through the perineum, cores of tissue are taken systematically, with or without targeting, under US guidance. Different fusion techniques (cognition, MRI-US fusion software, MRI in-bore) can be used to target pre-identified lesions on MRI. The sampling can be done either by free hand or using a brachytherapy grid. Robotic assisted prostate biopsy is also available on the market as an alternative. In recent years, there has been accumulating evidence showing that it is safe and feasible to perform TPPB under local anaesthesia. This may improve the uptake of TPPB as the preferred biopsy technique for prostate cancer., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/doi: 10.21037/tau.2019.12.40). The series “Muscle-Invasive Bladder Cancer” was commissioned by the editorial office without any funding or sponsorship. SS served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Translational Andrology and Urology from Jul 2018 to Jun 2020. The authors have no other conflicts of interest to declare., (2020 Translational Andrology and Urology. All rights reserved.)

Prostate biopsy is typically performed via either the transrectal or transperineal approach. MRI-targeted biopsy, whether using any of the three options of cognitive fusion, MRI-ultrasound fusion software, or in-bore MRI-guided biopsy, can also be performed via either transrectal or transperineal approaches. As an extension of traditional random prostate biopsy, the transrectal approach is far more commonly used for MRI-targeted biopsy due to its convenience. However, in the context of today's increasing multi-drug resistance of rectal flora, the transperineal approach is being used more often due to its lack of septic complications. In addition, only a first-generation cephalosporin, not a fluoroquinolone, is required as antibiotic prophylaxis. Evidence shows excellent detection rates of significant prostate cancer using magnetic resonance imaging (MRI)-targeted and/or systematic transperineal biopsy (TPB). However, there are no head-to-head studies comparing the different MRI-targeted methods within TPB. To provide truly patient-centred care, the biopsy technique using the safest method with the highest detection rate of significant cancer should be used. Depending on healthcare context and hospital resource utilization, MRI-targeted TPB is an excellent option and should be performed wherever available and feasible. Whilst building capacity for TPB in one's practice, the routine use of rectal culture swabs prior to any transrectal biopsies is strongly encouraged. Independent of biopsy route, the addition of systematic cores needs to be discussed with the patient weighing maximal detection of significant cancer against increased detection of insignificant lesions., Competing Interests: Conflicts of Interest: J Grummet: paid proctor for Biobot iSR’obot Mona Lisa, Biobot sponsored attendance at UAA ASM 2016; paid by Scanmedics for BK Ultrasound to run TPB Workshop 2014. B Hadaschik has funding from the German Research Foundation and the European Foundation for Urology and has received research support from MedCom and Uromed; none of these sources had any input into this article. The other authors have no conflicts of interest to declare.