The role of fusion-targeted prostate biopsy in clinically significant prostate cancer detection in elusive small-diameter lesions in high-volume prostates: Comparison of cognitive and fusion-targeted techniques.

Objective: To evaluate whether fusion biopsy provides an advantage in detecting clinically significant prostate cancer(csPCa) in elusive small-diameter lesions, especially in high volume prostates.

Material and methods: Data of 762 patients who underwent multiparametric magnetic resonance imaging(mpMRI) before prostate biopsy at single center between January 2017 and January 2024 were retrospectively assessed. All of these patients underwent combined cognitive and fusion targeted biopsy and systematic biopsy of suspicious lesions and transrectal ultrasonography guided systematic biopsy by 2 separate experienced radiologists(with histopathological evaluation completed for all specimens). Lesions were categorized by diameter (≤5 mm, 6-10 mm, >10 mm) and prostate volumes (≤30 mL, 31-70 mL, >70 mL). (All patients underwent 3T mpMRI, and lesions were scored using PI-RADS v2.1. The largest lesion with the highest PI-RADS score was considered the index lesion.) RESULTS: Patient characteristics, including clinical and radiological features, were balanced between cognitive and fusion biopsy groups. PI-RADS stratification showed similar detection rates for PI-RADS 3, 4 and 5 lesions between methods. For lesions ≤5 mm, fusion biopsy showed a significantly higher csPCa detection rate than cognitive biopsy (16.4% vs. 3%, P = 0.033). No clinical significant prostate cancer was detected in lesions ≤5 mm with prostate volumes >30 ml in cognitive biopsy group. For lesions 6-10 mm and >10 mm, detection rates were comparable between procedures.

Conclusion: MRI Fusion-targeted biopsy is particularly advantageous for smaller lesions and in settings where precise lesion targeting is critical. However, for larger lesions or institutions with skilled operators, cognitive-targeted biopsy remains a viable and effective alternative.