title: Magnetic Resonance and Ultrasound Image Fusion Supported Transperineal Prostate Biopsy Using the Ginsburg Protocol: Technique, Learning Points, and Biopsy Results.
abstract: Prostate biopsy supported by transperineal image fusion has recently been developed as a new method to the improve accuracy of prostate cancer detection.
  
  
  
  To describe the Ginsburg protocol for transperineal prostate biopsy supported by multiparametric magnetic resonance imaging (mpMRI) and transrectal ultrasound (TRUS) image fusion, provide learning points for its application, and report biopsy results. The article is supplemented by a Surgery in Motion video.
  
  
  
  This single-centre retrospective outcome study included 534 patients from March 2012 to October 2015. A total of 107 had no previous prostate biopsy, 295 had benign TRUS-guided biopsies, and 159 were on active surveillance for low-risk cancer.
  
  
  
  A Likert scale reported mpMRI for suspicion of cancer from 1 (no suspicion) to 5 (cancer highly likely). Transperineal biopsies were obtained under general anaesthesia using BiopSee fusion software (Medcom, Darmstadt, Germany). All patients had systematic biopsies, two cores from each of 12 anatomic sectors. Likert 3-5 lesions were targeted with a further two cores per lesion.
  
  
  
  Any cancer and Gleason score 7-10 cancer on biopsy were noted. Descriptive statistics and positive predictive values (PPVs) and negative predictive values (NPVs) were calculated.
  
  
  
  The detection rate of Gleason score 7-10 cancer was similar across clinical groups. Likert scale 3-5 MRI lesions were reported in 378 (71%) of the patients. Cancer was detected in 249 (66%) and Gleason score 7-10 cancer was noted in 157 (42%) of these patients. PPV for detecting 7-10 cancer was 0.15 for Likert score 3, 0.43 for score 4, and 0.63 for score 5. NPV of Likert 1-2 findings was 0.87 for Gleason score 7-10 and 0.97 for Gleason score ≥4+3=7 cancer. Limitations include lack of data on complications.
  
  
  
  Transperineal prostate biopsy supported by MRI/TRUS image fusion using the Ginsburg protocol yielded high detection rates of Gleason score 7-10 cancer. Because the NPV for excluding Gleason score 7-10 cancer was very high, prostate biopsies may not be needed for all men with elevated prostate-specific antigen values and nonsuspicious mpMRI.
  
  
  
  We present our technique to sample (biopsy) the prostate by the transperineal route (the area between the scrotum and the anus) to detect prostate cancer using a fusion of magnetic resonance and ultrasound images to guide the sampling.
authors.affiliation: CamPARI Clinic, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK; Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany.
authors.forename: Nienke
authors.initials: N
authors.lastname: Hansen
authors.affiliation: Department of Urology, University of Rome "Tor Vergata", Rome, Italy.
authors.forename: Giulio
authors.initials: G
authors.lastname: Patruno
authors.affiliation: Department of Urology, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: Karan
authors.initials: K
authors.lastname: Wadhwa
authors.affiliation: Department of Urology, University of Rome "Tor Vergata", Rome, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Gaziev
authors.affiliation: Department of Urology, University of Rome "Tor Vergata", Rome, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Miano
authors.affiliation: CamPARI Clinic, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK; Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK.
authors.forename: Tristan
authors.initials: T
authors.lastname: Barrett
authors.affiliation: CamPARI Clinic, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK; Department of Urology, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: Vincent
authors.initials: V
authors.lastname: Gnanapragasam
authors.affiliation: CamPARI Clinic, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK; Department of Urology, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Doble
authors.affiliation: CamPARI Clinic, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK; Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: Anne
authors.initials: A
authors.lastname: Warren
authors.affiliation: CamPARI Clinic, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK; Department of Urology, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: Ola
authors.initials: O
authors.lastname: Bratt
authors.affiliation: CamPARI Clinic, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK; Department of Urology, Addenbrooke's Hospital, Cambridge, UK. Electronic address: christof.kastner@addenbrookes.nhs.uk.
authors.forename: Christof
authors.initials: C
authors.lastname: Kastner
mesh_terms: D000368:Aged; D006801:Humans; D061705:Image-Guided Biopsy / Q000379:methods / Q000706:statistics & numerical data; D053783:Magnetic Resonance Imaging, Interventional / Q000379:methods*; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D010043:Outcome and Process Assessment, Health Care; D011467:Prostate / Q000000981:diagnostic imaging / Q000473:pathology; D017430:Prostate-Specific Antigen / Q000032:analysis; D011471:Prostatic Neoplasms / Q000175:diagnosis / Q000473:pathology; D012189:Retrospective Studies; D018084:Ultrasonography, Interventional / Q000379:methods*
chemical_list: D017430:Prostate-Specific Antigen
keywords: MRI-TRUS fusion; Magnetic resonance imaging; Prostate biopsy; Prostate cancer; Transperineal prostate biopsy