==inizio objective==

Introduction: In this series we aim to establish the added value of MR-cognitive guided biopsies (MRCGB) of tumor-suspicious regions (TSR) on multimodality MRI of the prostate following negative transrectal ultrasound (TRUS)-guided biopsies (1-2).

==fine objective==

==inizio methodsresults==

Between November 2011 to November 2015 in 165 patients with a persistent suspicion of prostate cancer after negative TRUS-guided biopsies (median: 3, range 1-7) a multimodality MRI (combination of T2-weighted, Dynamic Contrast Enhanced (DCE-MR) and diffusion-weighted (DWI) MRI, with an endorectal coil of the prostate was performed. Lesions suspicious for PCa on mp-MRI were classified according to Prostate Imaging-Reporting and Data System (PIRADS). In this class of patients we decided to proxeed to immediate biopsy only in lesions classified as PIRADS >3. This details the successive steps of the method (target detection, mp-MRI reporting, intermodality fusion, TRUS guidance to target, sampling simulation, sampling, TRUS session reporting, and quality insurance), how to optimize each, and the global indications of mp-MRI-targeted biopsies
Consequently Cognitive transrectal biopsy (GTB) was performed.

==fine methodsresults==

==inizio results==

Median PSA before GTB was 12.0 (range 4.1-22.5). Digital rectal examination was not suspect for malignancy in 150/165 patients. In 105 of 165 patients (64%) GTB showed histological malignancy. for lesions suspicious for PCa on mp-MRI were classified according to Prostate Imaging-Reporting and Data System (PIRADS). In this class of patients we decided to proxeed to immediate biopsy only in lesions classified as PIRADS >3. Consequently Cognitive transrectal biopsy (CTB) was performed 3 cores in target plus 12 cores The biopsy Gleason score (GS) within this group was distributed as follows: 52% GS≤6, 33% GS=7, 14% GS≥8. Out of 110 patients with a GS≤6 upon GTB, 70 had a PSA>10, 40 a positive (> 40) Prostate Health Index analysis; GS 4+3=7 tumor was found in these radical prostatectomy (RP) specimen.

==fine results==

==inizio discussions==

Performing TB under TRUS guidance, with the visual help of the MRI images alone is called “Visual registration,” but is also described as “cognitive registration” or “cognitive fusion” in the literature: the TRUS operator mentally relocates the target detected on the prebiopsy mp-MRI, based on its zonal topography and on anatomical landmarks that may exist beside the lesion (cyst, BPH nodule, calcification,…)
Visual registration is easier if MRI data is available in a separate workstation beside the ultrasound device, allowing the operator to review the MRI anatomy in T2-w sequences, relocate the target more precisely, check anatomical landmarks, and perform distance measurements described above. If the physician performing the biopsies did not interpret the MRI, he will also take benefit of a schematic interpretation report (3-5)

==fine discussions==

==inizio conclusion==

mMRI guided GTB of the prostate is an important addition to the diagnostic measures available in patients with repetitive negative TRUS-guided prostate biopsies and a persistent suspicion of prostate cancer. The performance of MRGB in this series is superior to the reported yield of repeat TRUS-guided biopsies or saturation biopsies in the literature. Overdiagnosis of insignificant cancer using PIRADS > 3 it is no more a concern, in fact in our series biopsy GS indicates a strong suspicion of significant prostate cancer in most cases (6).In comparison with other MRI-US fusion techniques Cognitive biopsy is easier to learn, cheapest and simpler, making it compatible with daily office practice and a potential inclusion in the standard diagnostic pathway of PCa.

==fine conclusion==

==inizio references==

1.Kurhanewicz J., Vigneron D., Carroll P., Coakley F. Multiparametric magnetic resonance imaging in prostate cancer: present and future. Current Opinion in Urology. 2008;18(1):71–77. doi: 10.1097/MOU.0b013e3282f19d01. [PMC free article] [PubMed] [Cross Ref]

2. Haffner J., Lemaitre L., Puech P., Haber G.-P., Leroy X., Jones J. S., Villers A. Role of magnetic resonance imaging before initial biopsy: comparison of magnetic resonance imaging-targeted and systematic biopsy for significant prostate cancer detection. BJU International. 2011;108(8, part 2):E171–E178. doi: 10.1111/j.1464-410X.2011.10112.x. [PubMed] [Cross Ref]

3. Lemaitre L., Puech P., Poncelet E., Bouyé S., Leroy X., Biserte J., Villers A. Dynamic contrast-enhanced MRI of anterior prostate cancer: morphometric assessment and correlation with radical prostatectomy findings. European Radiology. 2009;19(2):470–480. doi: 10.1007/s00330-008-1153-0. [PubMed] [Cross Ref]

4. Puech P., Potiron E., Lemaitre L., Leroy X., Haber G.-P., Crouzet S., Kamoi K., Villers A. Dynamic contrast-enhanced-magnetic resonance imaging evaluation of intraprostatic prostate cancer: correlation with radical prostatectomy specimens. Urology. 2009;74(5):1094–1099. doi: 10.1016/j.urology.2009.04.102. [PubMed] [Cross Ref]

5. Villers A., Puech P., Mouton D., Leroy X., Ballereau C., Lemaitre L. Dynamic contrast enhanced, pelvic phased array magnetic resonance imaging of localized prostate cancer for predicting tumor volume: correlation with radical prostatectomy findings. The Journal of Urology. 2006;176(6):2432–2437.
6. Baris Turkbey, Peter L. Choyke PIRADS 2.0: what is new? Diagn Interv Radiol. 2015 September; 21(5): 382–384.

==fine references==

==inizio objective==

Prostate-specific membrane antigen (PSMA) is a membrane carboxypeptidase type II, widely over-expressed in prostate cancer cells. Recently, an innovative 68Ga–labeled ligand have been designed to target membrane PSMA in diagnostic PET/CT.
The aim of this prospective study is to evaluate the added value of PET / CT with 68Ga-PSMA in identifying the source of PSA biochemical recurrence in patients radically treated for prostate cancer and negative/equivocal conventional imaging such as, trans-rectal ultrasound, bone scan, FCH PET / CT and CT / MRI.

==fine objective==

==inizio methodsresults==

Since December 2015, we have enrolled 13 patients with suspected biochemical recurrence of prostate cancer (Gleason Score: 7 to 9), previously treated with either radical prostatectomy (RP) (9 patients), or external beam radiotherapy (RT) (3 patients) or brachytherapy (BT) (1 patient). At enrollment all patients had a serum PSA value > 1.0 ng / ml (range 1,35-13,4 ng/ml), negative or equivocal conventional imaging and had been off hormonal and radiation therapy for at least 6 months.
68Ga-HBED-CC-PSMA will be prepared and according to national regulations, good radiopharmaceutical practices (GRP) as outlined in specific EANM guidelines, using a product of Eazy synthesis module (Eckert and Zieckert , Germany).
PET / CT, was performed from head to mid-thighs, 50 minutes after intravenous administration through an indwelling catheter to avoid extravasation at a dosage of 100-200 MBq of 68Ga-PSMA. Patients should not be fasting before scan and should void before scanning to reduce the background noise as well as the radiation dose to the kidneys and bladder.
68Ga-PSMA PET / CT scans were performed on an integrated PET / CT system (Discovery LS camera, General Electric Medical Systems, Waukesha, WI) in 2D acquisition mode for 3 minutes per bed position.

==fine methodsresults==

==inizio results==

68Ga-PSMA PET / CT was positive in 10 patients (72%), equivocal in 1 patient and negative in 2/11 patients.
In particular, 8 patients presented an intense radiotracer uptake at the prostate gland/bed (four patients submitted to RP and four patients underwent RT). One patient showed nodal tracer uptake while one patient had radiotracer uptake in two lung nodules.
In one patient 68Ga-PSMA PET / CT showed equivocal uptake in some retroperitoneal nodes, whereas FCH PET/CT showed indeterminate uptake at the right clavicle.
The remaining two patients showed no localization of intense radiotracer uptake; both had been treated with PR and subsequently RT.

==fine results==

==inizio discussions==

A whole-body imaging technique detecting the source end extent of prostate recurrence in radically-treated patients experiencing biochemical recurrence is essential to inform the selection of the most appropriate therapeutic strategy. Currently, Choline PET / CT is used as gold standard in clinical practice, but suboptimal diagnostic accuracy has been reported in large cohorts, mainly due to a lack of specificity. In order to overcome this drawback a novel tracer, 68Ga-PSMA, is currently being tested in the biochemical recurrence scenario showing promising results both in terms of sensitivity and specificity. The preliminary experience at our Institution, among the first in Italy to test this novel tracer, suggest similar excellent results.

==fine discussions==

==inizio conclusion==

Our preliminary data, awaiting clinical confirmation, suggest that PET/CT with the novel tracer 68Ga-PSMA is an effective tool allowing the detection and the assessment of extent of biochemically-relapsing prostate cancer with negative or equivocal conventional imaging. In our cohort of patients with a negative/equivocal 18F-Choline PET/CT , 68Ga-PSMA has proven particularly effective in detecting prostate/prostate bed-confined recurrence over pelvic or extra-pelvic nodal disease. The confirmation of these early results will prompt the validation of 68Ga-PSMA diagnostic accuracy over Choline PET/CT in a larger cohort of patients, with a potential gain in enabling earlier recurrence detection and improving patient care management.

==fine conclusion==

==inizio references==

1. AIOM linee guida nel carcinoma della prostata 2012.
2. Hodolic M. Role of (18)F-choline PET/CT in evaluation of patients with prostate carcinoma. Radiol Oncol. 2011.
3. Bachmann LM et al. The role of 11C-choline and 18F-choline PET and PET/CT in prostate cancer: a systematic review and meta-analysis. Eur Urol 2013.
4. Fanti S. et al. Role of 11C-choline PET/CT in the restaging of prostate cancer patients with biochemical relapse and negative results at bone scintigraphy. Eur J Radiol 2012; Aug 81 (8).
5. Ali Afshar-Oromieh et al. Comparison of PET imaging with a 68 Galabelled PSMA ligand and 18F-choline based PET/CT for the diagnosis of recurrent prostate cancer. Eur J Nucl Med Mol Imaging. 2014, 41:11-20.
6. Ali Afshar-Oromieh et al. The diagnostic value of PET/CT imaging with the 68Ga- labelled PSMA ligand HBED-CC in the diagnosis of recurrent prostate cancer. Eur J Nucl Med Mol Imaging, 2015, 42: 197–209.
7. C.M. Zechmann et al. PET imaging with a 68 Ga labeled PSMA ligand for the diagnosis of prostate cancer: biodistribution in humans and first evaluation of tumor lesions. Eur J Nucl Med Mol Imaging. 2013.
8. Benjamin T. Ristau. et al. the prostate specific membrane antigen: lessons and current clinical implications from 20 years of research. Urologic Oncology: seminars and original investigations 2013.
9. Joseph R. Osborne et al. Prostate specific membrane antigen based imaging. . Urologic Oncology: seminars and original investigations 2012.

==fine references==

==inizio objective==

Prostate biopsy, conducted with aim to detect prostate cancer, is not free from complications, with a post biopsy prostatitis rate ranging between 1 and 5% [1]; prostatitis is a frequent cause of hospitalization and can lead to urosepsis, a life threatening condition.
EAU Guidelines recommend antibiotic phrophylaxis with fluoroquinolones, that provide high bioavailability and excellent penetration into the prostate tissue, preferring to ciprofloxacin ofloxacin [2].
The Global Prevalence Study of Infections in Urology study documented how the transrectal approach is more prevalent among urologists (97%), as well as quinolones are the most widely used prophylaxis (91%).
However, especially at our latitudes, in recent years there has been developed Escherichia coli strains resistant to fluoroquinolones.
A recent study by Taylor et al, which evaluated 865 patients, that underwent transrectal prostate biopsy at the Vancouver General Hospital, showed that 19% of the subjects presented coliform strains resistant to ciprofloxacin, and the patients most at risk of developing these resistances were patients with cardiac valve replacement history and who had used fluoroquinolones within the previous 3 months [3].
The aim of our study was to evaluate efficacy and safety of a new phrophylaxis protocol using gentamicin 3 mg/kg in association with metronidazol 500 mg single shot in patients undergoing 20 cores transrectal ultrasound guided prostate biopsy in a single urologic center in Italy.

==fine objective==

==inizio methodsresults==

A prosepective study was conducted between June and Decemeber 2016 in our center; we prospectively evaluated 136 patients undergoing 20 core ultrasound prostate biopsy.
The procedures were performed according to the indications of the EAU Guidelines for prostate cancer detection or in adherence of a prostate cancer active surveillance protocol.
The following pre operative characteristics were registered and analyzed: age, comorbidities according to Chralson comorbidity index, serum total PSA. Patients were pre operative evaluated with urinalysis and urin culture.
Prior to ultrasound, a digital rectal exam was conducted and prostate volume was extimated trough a rectal ultrasound.
On the morning of the procedure, rectal enema was performed, and antibiotic prophylaxis with gentamicin 3 mg/kg and metronidazol 500 mg was administered to all patients.
All the patients underwent a 20 cores transrectal ultrasound guided prostate biopsy and were discharged in the same day.
Two weeks after the procedures the patients were evaluated in ou outpatients clinic, with the aim to communicate the histological examination and to assess possible complications.
Pre and post operative complication were recordered and registerd according to Clavien Dindo classification.

==fine methodsresults==

==inizio results==

We prospectively evaluated 136 patients that received single shot prophylaxis with gentamicine 3mg/kg and metronidazol 500 mg; 98/136 (72%) received metronidazol ev, whereas 38 (28%) x os.
Mean age of the cohort was 65.71 + 8.49 years, whereas more represented Charlson comorbidity index was 0 (65%).
Mean PSA was 11.32 + 19.00ng/ml and mean prostate volume was 42.91 + 20.99cc.
59% of the patients presented a negative rectal examination; mean operative time was 11.52 + 5.32min .
Only 12 pts had a positive urine culture, and only one of this was resistant to quinolones; 10/53 rectal swabs was positive, with one ESBL E. Coli resistant to quinolones.
22% of our patients developed fever or dysuria after the procedure; only 4/29 presented a positive urinalysis, and none of these was quinolones resistants; moreover, 5 patients presented positive haemoculture, only one resistant to quinolones.
Due to the high incidence of fever and prostatitis, we evaluated the presence of complications risk factors.
The two groups, nevertheless, did not presented any differences regarding age (65.6 + 8.26 VS 63.67 + 9.23), CCI, presence of positive urine culture or positive rectal swab ( all p > 0.05).

==fine results==

==inizio discussions==

In our cohort, the presence of fluoroquinolones resistant strains in urinary culture was lower than expected.
Nevertheless, 22% of our patients developed fever or acute prostatitis after the procedure, documenting that a one shot prophylaxis with gentamicine 3 mg/kg and metronidazol 500 mg is not a safe or effective pre operative prophylaxis.
Our study presents, moreover, possible limitations, as the single center design, the multisurgeon basis, the relatively low number of patients enrolled and lack of randomization.
Larger, randomized prospective trials are needed, with the aim to establish a safer and cost effective prophylaxis for patients undergoing ultrasound guided rectal prostate biopsy.

==fine discussions==

==inizio conclusion==

In our cohort, the presence of fluoroquinolones resistant strains in urinary culture was lower than expected, whereas the post procedure fever / prostatitis / readmission rate was significatively higher than in literature (22%; 29/136 patients).
We did not, find, moreover, any differences between the two groups of analyzed patients; our data suggest, therefore, that a one shot prophylaxis with gentamicine 3 mg/kg and metronidazol 500 mg is not a safe or effective procedure for patients undergoing transrectal ultrasound guided prostate biopsy.
Due to the limitations of our study, larger randomized trials are needed, with the aim to establish a cost effective prophylaxis.

==fine conclusion==

==inizio references==

1. Linvert K.A., Kabalin J.N., Terris M.K. Bacteremia and bacteriuria after transrectal ultrasound guided prostate biopsy. J Urol. 2000;164:76–80.
2. Aron M, Rajeev TP, Gupta NP. Antibiotic prophylaxis for transrectal needle biopsy of the prostate: a randomized controlled study. BJU Int 2000 Apr:85(6):682-5.
3. Taylor S, Margolick J, Abughosh Z, Goldenberg SL, Lange D, Bowie WR, Bell R, Roscoe D, Machan L, Black P. Ciprofloxacin resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy. BJU Int. 2013 May;111(6):946-53.

==fine references==

==inizio objective==

The robotic technology has a shorter learning curve and some technical advantages instead of classical laparoscopy (increased number of degrees of freedom and three-dimensional visualization of the operative field) (1). A difficulty of laparoscopic surgery involves converting two-dimensional (2D) images into three-dimensional 3D images and depth perception rearrangement. 3D imaging may remove the need for depth perception rearrangement and therefore have clinical benefits (2) (3). The aim of this study was to clarify if 3D images are really beneficial in the performance of laparoscopic radical prostatectomy compared with 2D imaging systems and to analyze oncological and functional outcomes at a short-term follow-up.

==fine objective==

==inizio methodsresults==

From January 2015 to November 2015, 92 patients underwent a laparoscopic extraperitoneal radical prostatectomy (LERP) at our hospital. Oh these, 50 patients underwent a 3D-LERP (27 patients underwent an iliac/obturator lymph node dissection) and 42 patients underwent a 2D-LERP (24 patients underwent an iliac/obturator lymph node dissection). We divided our department surgeons into two subgroups according to the number of surgeries (less and more than 50 LERP). 41 out of 50 3D-LERP were performed by a surgeon with more than 50 LERP. 29 out of 42 2D-LERP were performed by a surgeon with more than 50 LERP. 2D-HD Storz® system was used to perform 2D procedures and Einstein Vision® 3D system was used to perform 3D procedures. We hypothesized that VUA (vesico-urethral anastomosis) was one of the most difficult and challenging procedures. The primary outcome was the time of VUA. Secondary outcomes were operative time, blood loss, PSMs (post surgical margins) rate, recovery of continence according to the validated questionnaire Incontinence Quality of Life (I-QoL) and the feasibility of basic tasks. The feasibility of basic tasks were measured by eight questionnaires using 7-point Likert scales. Mean values with standard deviations (±SD) were computed and reported for all items. Statistical significance was achieved if p-value was ≤0.05 (two-sides). Categorical data were compared using Pearson’s chi-squared test (χ2).

==fine methodsresults==

==inizio results==

Mean time +/- SD of VUA using the van Velthoven technique (4) was 13.8+/-4.8 min using the 3D imaging system and 14.6+/-4.5 min using the 2D imaging system. No significant difference was observed (p=0.41). Mean time +/- SD of VUA was statistically different in the subgroups of surgeons with less than 50 LERP (14.2+/-3.5 min vs 17.2+/-2.9 min, p=0,04) but no significant difference was observed in the subgroups of surgeons with more than 50 LERP (13.2+/-2.8 vs 13.6+/-3.1 p=0.58).
Mean total operative time +/- SD was 105,6 +/- 27,5 (50-190 min) using 3D imaging system and 106,4 +/- 36,1 (45-235 min) using 2D imaging system. No significant difference was observed (p=0.9043).
The same trend was seen in the subgroup of surgeon with more than 50 LERP (100.25+/-25.5 min vs 101.4+/-39,6 p=0,88) and in the subgroup of surgeon with less than 50 LERP (115.68+/-20.1 vs 113.8+/-29.5, p=0,87).
No significant differences were seen in mean blood loss between the two groups (mean +/- SD 306,2 +/- 230 in the 3D-LERP group and 316.8 +/- 247.9 in the 2D-LERP group, p=0.83).
No conversion from the 3D to the 2D imaging system during LRP was observed.
Feasibility of basic tasks, was significantly better using the 3D imaging system in all questionnaires except for one (Table 1). No differences in PSMs were seen (P=0.93). I-QoL questionnaires showed a significant quality of life improvement at the first month in the 3D-LERP group (91,6+/-7) compared to the 2D-LERP group (81,2+/-5) (p =0). I-QoL questionnaires did not show a significant quality of life improvement at the third month (93,5+/-5 vs 91,9 +/-6) (p =0.17). The overall continence rate did not reach a statistically significant difference at 1 month follow-up (90% vs 88%), (P=0,77) and at 3 month follow-up after pelvic floor rehabilitation (96% vs 94%), (P=0,51).

==fine results==

==inizio discussions==

Classical laparoscopic surgery is limited by a two-dimensional vision that does not allow perception of the operative field. The lack of depth perception has repercussions both on the learning curve, and in the possibility for the surgeon to maneuver the instruments with an accuracy comparable to that which would occur in the same “open” operation. In this study, we demonstrate that the 3D imaging system do not decrease the time of VUA compared with the conventional 2D imaging system except for surgeons who are at the beginning of their learning curve. The 3D imaging system do not decreased the mean total operative time compared with the conventional 2D imaging system. No significant differences were seen in mean blood loss between the two groups. Moreover PSMs rate was similar between the two groups. Meticulous handling and tissue dissection obtained with the auxilium of the 3D view have allowed earlier continence recovery according to I-QoL questionnaires. This could be mainly related to less trauma and greater sphincter- structures saving (5). Although the trend is clearly favorable to the 3D-LERP group, the overall continence rate did not reach a statistically significant difference at the first month and at the third month follow-up and I-QoL questionnaires did not show a significant quality of life improvement at the third month follow-up after pelvic floor rehabilitation.
The definition of continence was based on a specific question appropriate to reflect the range of incontinence severity: “How many pads/day did you usually use to control urine leakage during the last 4 weeks?”. We considered “dry” patients without any loss of urine (no pads/day) or those who used a safety pad/day. There is no validated way to measure subjectively the feasibility of different tasks during operation. Therefore, in this study, we measured surgeons’ subjective evaluation of surgical feasibility. In all questionnaires but one, 3D was superior to 2D imaging. These results were the same as those reported for cholecistectomy (6).

==fine discussions==

==inizio conclusion==

In conclusion, performance time of VUA in LERP was not statistically different between 2D and 3D imaging except for surgeon with a low experience in LERP. A positive trend for a better recovery of continence at 1 month follow-up was seen in the 3D group. The 3D laparoscopy may be an intermediate step between the standard 2D laparoscopy and robot assisted laparoscopy, allowing the combination of the low cost of the first with the 3D technology of the second. The experience of surgeon may decrease the advantage of 3D imaging. Further studies are necessary to better comprehend the role of 3D-LERP in radical prostatectomy.

==fine conclusion==

==inizio references==

1- Ku JY, Ha HK.Learning curve of robot-assisted laparoscopic radical prostatectomy for a single experienced surgeon: comparison with simultaneous laparoscopic radical prostatectomy. World J Mens Health. 2015 Apr;33(1):30-5. doi: 10.5534/wjmh.2015.33.1.30. Epub 2015 Apr 23.
2- Su LM, Vagvolgyi BP, Agarwal R, Reiley CE, Taylor RH, Hager GD Augmented reality during robot-assisted laparoscopic partial nephrectomy: toward real-time 3D-CT to stereoscopic video registration. Urology,2009 73:896–900
3- Teber D, Guven S, Simpfendorfer T, Baumhauer M, Guven EO, Yencilek F et al. Augmented reality: a new tool to improve surgical accuracy during laparoscopic partial nephrectomy? Preliminary in vitro and in vivo results. Eur Urol 2009 56:332–338

4-Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV. Technique for laparoscopic running urethrovesical anastomosis:the single knot method. Urology. 2003 Apr;61(4):699-702.
5- Schlomm T, Heinzer H, Steuber T, Salomon G, Engel O, Michl U, Haese A, Graefen M, Huland H. Full functional-length urethral sphincter preservation during radical prostatectomy. Eur Urol. 2011;60:320–9.

6- Hanna GB, Shimi SM, Cuschieri A (1998) Randomised study of influence of two-dimensional versus threedimensional imaging on
performance of laparoscopic cholecystectomy. Lancet 351:248–251

==fine references==

==inizio objective==

Aims of our study were to verify the success rate of Multiparametric Magnetic Resonance (mpMRI)-TRUS
Fusion Imaging guided targeted prostate biopsy in a primary baseline setting, and to compare the diagnostic performance of Fusion Imaging guided biopsy with that of conventional 16-cores transrectal systematic conventional TRUS-guided biopsy. The primary objective is to verify the success rate of baseline biopsy, performed for lesion targeted with MRI-US fusion imaging.

==fine objective==

==inizio methodsresults==

68 patients (mean age ± standard deviation (SD): 65 ± 16 y, range: 48–78 y) with clinical suspicion of prostate cancer (PCa) (negative rectal examination and elevated PSA levels: 12.07 ± 4.71) underwent a mpMRI to detect nodular lesions. Exclusion criteria were the inability to attend an MRI examination, controindications to MRI examination and uncorrectable coagulopathy. The degree of PCa suspicion from mpMRI findings was classified according to the PI-RADS scoring system. We performed mpMRI-TRUS Fusion Imaging guided biopsy on suspected areas, from 2- 4 cores were keep from any suspicious areas,
and 16-cores systematic biopsies in the whole gland. mpMRI was performed with a 1,5 Tesla whole body scanner (GE Healthcare) with a phased array coil. All biopsy procedures were performed in an operating room with a LOGIQ-E9 Ultrasound machine with V-NAV fusion imaging system and two position sensors attached to the base of the probe.

==fine methodsresults==

==inizio results==

All the mpMRI examinations showed almost a suspected area by means of T2 weighted morphological sequences, DWI and/or Perfusion dynamic imaging. All mpMRI detected lesions were not visible on conventional TRUS. Targeted biopsies were performed on 82 nodules in 68 patients and the final histological diagnosis was: 36 adenocarcinoma, 1 ASAP, 1 HGPIN, 22 prostatic inflammation e 8 negative biopsies. 16-Core Systematic Biopsies were performed in the same 68 patients and the final histological diagnosis in the whole gland was: 20 adenocarcinoma, 1 HGPIN, 20 prostatic inflammations, 27 negative biopsies. The combination oft he two type of biopsies showed these histological results: 46 adenocarcinoma, 1 HGPIN, 1 ASAP, 8 prostatic inflammation and 12 negative biopsies.

==fine results==

==inizio discussions==

The results confirm that Targeted biopsies have detection rates superior to systematic biopsies. This was especially true for higher-grade disease. The higher-grade carcinoma is the disease which should be treated with radical surgeon so the importance to perform accurate biopsies.The prostate is much larger than 16-Core in a systematic biopsy and it is widely accepted that there are regions of the gland, including the central and anterior portions, that are commonly undersampled and in which tumors cannot be detected on digital rectal examination. Targeted biopsies can be particularly useful in indicating to the physician the importance in sampling these regions. There are studies which reported that anteriorly located cancerous lesions were missed in up to 46% to 16-Core systematic biopsy.

==fine discussions==

==inizio conclusion==

Among men undergoing biopsy for suspected prostate cancer, targeted biopsy, compared with systematic ultrasound-guided biopsy, was associated with increased detection of high-risk prostate cancer and decreased detection of low-risk prostate cancer.
MRI-TRUS Fusion Imaging seems to be a powerful tool for primary diagnosis of prostatic cancer and an important guidance system for baseline biopsy on supected areas. The development of this technique could lead to the reduction of systematic sampling of the prostate. Reducing the use of systematic biopsies with TRUS-guidance alone. This system MRI-TRUS Fusion Imaging has the advantage of using a standard ultrasound scanner without the need to have a dedicated system for prostate biopsies; in this way, costs are reduced and the learning curve is shortened.

==fine conclusion==

==inizio references==

European Association of Urology, Guidelines 2014
Eichler K, Hempel S, Wilby J, et al. Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a systematic review. J Urol 2006 May;175(5):1605
Bratan F, Niaf E, Melodelima C, et al. Influence of imaging and histological factors on prostate cancer detection and localisation on multiparametric MRI: a prospective study. Eur Radiol 2013 Jul;23(7):2019-29.

Kaplan I, Oldenburg NE, Meskell P, et al. Real time MRI-ultrasound image guided stereotactic prostate biopsy. Magn Reson Imaging. 2002; 20:295–299.
Pinto PA, Chung PH, Rastinehad AR, et al. Magnetic resonance imaging/ultrasound fusion guided prostate biopsy improves cancer detection following transrectal ultrasound biopsy and correlates with multiparametric magnetic resonance imaging. J Urol. 2011; 186:1281–1285.
Barentsz J.O. et al. ESUR prostate MR guidelines 2012. Eur Radiol (2012) 22:746–757
Alonzi R, Padhani AR, Allen C (2007) Dynamic contrast enhanced MRI in prostate cancer. Eur J Radiol 63:335–350
Junker D, et al. Multiparametric Magnetic Resonance Imaging/ Transrectal Ultrasound Fusion Targeted Biopsy of the Prostate: Preliminary Results of a Prospective Single-Centre Study . Urol Int 2015 10.1159

==fine references==

==inizio objective==

An extended Prostate Biopsy (10–12 cores) remains the standard for the initial diagnostic evaluation of a suspicious prostate1.The rate of prostate cancer (PCa) detection for a first systematic transrectal ultrasound-guided biopsy (TRUS-GB) is typically 30–50%2. Nevertheless, clinically significant PCa can be missed even after several repeat TRUS-GB. This applies especially to patients with anteriorly located tumors, which are frequently underdiagnosed by TRUS-GB3. Multiparametric MRI of the prostate is able to detect clinically relevant CaP4. The ability to visualize some PCa on MRI has brought the opportunity to use those images as targets for needle biopsy by incorporating (i.e. fusing) MRI into a needle-aiming or targeting method5.
The aim of the study was to evaluate the accuracy of targeted magnetic resonance imaging (MRI)-ultrasound fusion–guided biopsy (FUS-GB) in the diagnosis of clinically significant prostate cancer (PCa) and to compare PCa detection between FUS-GB alone and FUS-GB + TRUS-GB in patients with prion negative biopsies for cancer.

==fine objective==

==inizio methodsresults==

Between February 2014 and January 2016, we consecutively included in the study all men who underwent multiparametric MRI and then MRI/US fusion biopsy with previous history of negative prostate biopsy and a PSA level of 4-20 ng/mL. Overall, 223 men were included in this study, enrolled in 3 centers: Dept of Urology Hospital San Giovanni Bosco of Turin – Clinica Fornaca of Turin – Dept of Urology Campus Bio Medico of Rome. All men underwent a 12 extended-cores protocol plus 2-3 targeted cores on the multiparametric MRI (mpMRI) index lesion. The UroStation™ (Koelis, France) and a V10 ultrasound system with an end-fire 3D TRUS transducer were used for the fusion images procedure.

==fine methodsresults==

==inizio results==

The mean patient age was 67 (48-77) years old, the mean PSA level at biopsy was 9.4 (2.3-20) ng/mL. pathologic report of previous biopsies were : 145 BPH, 40 phlogosis, 12 PIN hg, 26 ASAP. 123/223 patients (55.1%) had positive biopsies with Gleason score 3+3 in 63 patients (51%), Gleason score 3+4 or 4+3 in 48 patients (39%), Gleason score 4+4 in 12 patients (10%). MRIdetected at least 1 suspicious area in 160 patients (72%), 2 or more suspicious area in 63 patients (28%). The median time between MRI and biopsy was 30 days. The number of men diagnosed with clinically significant cancer was 36 (29%) with TRUS-GB and 59 (48,3%) with FUS-GB.

==fine results==

==inizio discussions==

Three methods of MRI guidance are available for targeted prostate biopsy: cognitive fusion, ; direct MRI-guided biopsy, performed within an MRI tube; and software coregistration of stored MRI with realtime ultrasound, using a fusion device6.
In FUS-GB, the operator images the prostate using ultrasound, as performed for the past several decades; while thus viewing the prostate, the MRI of that prostate, which is performed beforehand and stored in the device, is fused with real-time ultrasound using a digital overlay, allowing the target(s), previously delineated by a radiologist, to be brought into the aiming mechanism of the ultrasound machine. our registration system uses an elastic (deformable) image registration that is performed with a 3D TRUS probe to acquire prostatic volume. Before each biopsy 3D TRUS acquisition is performed to calculate the deformation of the prostate shape on MR images. Thus, it is not a real-time technique but the spatial accuracy of the system after image registration was reported to be close to 1 mm. In our study, target biopsy with computerized MRI-TRUS image registration significantly improved cancer detection over that of systematic transrectal ultrasound-guided biopsy.This improvement was for both the clinically significant cancers that for clinically insignificant cancers. FUS-GB alone missed only 2 high grade cancers detected by TRUS-GB.

==fine discussions==

==inizio conclusion==

In our experience, MRI–ultrasound fusion for lesion targeting is likely to result in fewer and more accurate prostate biopsies than the current use of systematic biopsies with ultrasound guidance alone.
MRI-ultrasound fusion–guided biopsy detected more men with clinically significant PCa thansystematic transrectal ultrasound-guided biopsy. The limit of this method is that it is indirect, involves use of an additional device and requires specialized operator training. The advantage is that it can be performed within minutes in an outpatient clinic setting under local anaesthesia, using techniques familiar for several decades. Results using a fusion device are very promising. Targeted biopsy has the potential to reduce overdiagnosis. Randomized extended and saturation prostate biopsy have dominated the prostate biopsy scenario in the past, they are still the gold standard, but probably they do not represent the future

==fine conclusion==

==inizio references==

1. Eichler K, Hempel S, Wilby J, et al. Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a systematic review. J Urol 2006 May;175(5):1605-12.
2. Cormio L, Scattoni V, Lorusso F, et al. Prostate cancer detection rates in different biopsy schemes. Which cores for which patients? World J Urol 2014;32:341–6.
3. Komai Y, Numao N, Yoshida S, et al. High diagnostic ability of multiparametric magnetic resonance imaging to detect anterior prostate cancer missed by transrectal 12-core biopsy. J Urol 2013; 190:867–73
4. Barentsz JO, Richenberg J, Clements R, et al. ESUR prostate MR guidelines 2012. Eur Radiol. 2012; 22:746–757. [PubMed: 22322308] . Current clinical guidelines for multiparametric prostate MRI.
5. Moore CM, Robertson NL, Arsanious N, et al. Image-guided prostate biopsy using magnetic resonance imaging-derived targets: a systematic review. Eur Urol. 2012.
6. Leonard Marksa, Shelena Young, and Shyam Natarajan. MRI–ultrasound fusion for guidance of targeted prostate biopsy. Current opinion Volume 23 _ Number 1 _ January 2013

==fine references==