Investig Clin Urol.  2018 Nov;59(6):363-370. 10.4111/icu.2018.59.6.363.

Initial experience of magnetic resonance imaging/ultrasonography fusion transperineal biopsy: Biopsy techniques and results for 75 patients

  • 1Department of Urology, Korea University Medical Center, Korea University School of Medicine, Seoul, Korea.


The aim of this study is to describe the technique and to report early results of transperineal magnetic resonance imaging and ultrasonography (MRI-US) fusion biopsy.
A total of 75 patients underwent MRI-US fusion transperineal biopsy. Targeted biopsy via MRI-US fusion imaging was carried out for cancer-suspicious lesions with additional systematic biopsy. Detection rates for overall and clinically significant prostate cancer (csPCa) were evaluated and compared between systematic and targeted biopsy. In addition, further investigation into the detection rate according to prostate imaging reporting and data system (PI-RADS) score was done. Results of repeat biopsies were also evaluated.
Overall cancer detection rate was 61.3% (46 patients) and the detection rate for csPCa was 42.7% (32 patients). Overall detection rates for systematic and targeted biopsy were 41.3% and 57.3% (p < 0.05), respectively. Detection rates for csPCa were 26.7% and 41.3%, respectively (p < 0.05). The cancer detection rates via MRI fusion target biopsy were 30.8% in PI-RADS 3, 62.1% in PI-RADS 4 and 89.4% in PI-RADS 5. Rates of csPCa missed by targeted biopsy and systematic biopsy were 0.0% and 25.0%, respectively. The cancer detection rate in repeat biopsies was 61.1% (11 among 18 patients) in which 55.5% of cancer suspected lesions were located in the anterior portion.
Transperineal MRI-US fusion biopsy is useful for improving overall cancer detection rate and especially detection of csPCa. Transperineal MRI-US targeted biopsy show potential benefits to improve cancer detection rate in patients with high PI-RADS score, tumor located at the anterior portion and in repeat biopsies.


Biopsy; Magnetic resonance imaging; Prostatic neoplasms; Ultrasonography

MeSH Terms

Information Systems
Magnetic Resonance Imaging
Prostatic Neoplasms


  • Fig. 1 (A) The set-up of the probe which was attached to a brachytherapy grid with 5-mm spacing and cradle. (B) Biopsy through grid guided by fusion software.

  • Fig. 2 (A) Sagittal Real-time US targeting of the ROI. ROI 1 (red), ROI 2 (purple), and prostate contour (green). Note that the 3-D model is made, demonstrating the biopsy tract (yellow rod). (B) A 3-D magnetic resonance imaging model assembled by axial and sagittal plane images. ROI, region of interest; 3-D, three-dimensional.

  • Fig. 3 (A) A 69-year-old man with prostate-specific antigen (PSA) 8.7, Gleason 4+3 cancer in 5 core after initial biopsy. Left transitional lesion of highest suspicion identified on multiparametric magnetic resonance imaging (arrows). (B) A 67-year-old man with PSA 5.6, Gleason 3+3 cancer in 2 core after initial biopsy (from left to right; T2-weighted image, Apparent-diffusion coefficient, dynamic contrast enhancement T1WI) (arrows).


1. Nevoux P, Ouzzane A, Ahmed HU, Emberton M, Montironi R, Presti JC Jr, et al. Quantitative tissue analyses of prostate cancer foci in an unselected cystoprostatectomy series. BJU Int. 2012; 110:517–523. PMID: 22192756.
2. Hu Y, Ahmed HU, Carter T, Arumainayagam N, Lecornet E, Barzell W, et al. A biopsy simulation study to assess the accuracy of several transrectal ultrasonography (TRUS)-biopsy strategies compared with template prostate mapping biopsies in patients who have undergone radical prostatectomy. BJU Int. 2012; 110:812–820. PMID: 22394583.
3. Schoots IG, Roobol MJ, Nieboer D, Bangma CH, Steyerberg EW, Hunink MG. Magnetic resonance imaging-targeted biopsy may enhance the diagnostic accuracy of significant prostate cancer detection compared to standard transrectal ultrasound-guided biopsy: a systematic review and meta-analysis. Eur Urol. 2015; 68:438–450. PMID: 25480312.
4. Hambrock T, Somford DM, Hoeks C, Bouwense SA, Huisman H, Yakar D, et al. Magnetic resonance imaging guided prostate biopsy in men with repeat negative biopsies and increased prostate specific antigen. J Urol. 2010; 183:520–527. PMID: 20006859.
5. Kasivisvanathan V, Dufour R, Moore CM, Ahmed HU, Abd-Alazeez M, Charman SC, et al. Transperineal magnetic resonance image targeted prostate biopsy versus transperineal template prostate biopsy in the detection of clinically significant prostate cancer. J Urol. 2013; 189:860–866. PMID: 23063807.
6. Loch T, Eppelmann U, Lehmann J, Wullich B, Loch A, Stöckle M. Transrectal ultrasound guided biopsy of the prostate: random sextant versus biopsies of sono-morphologically suspicious lesions. World J Urol. 2004; 22:357–360. PMID: 15672278.
7. Shoji S, Hiraiwa S, Endo J, Hashida K, Tomonaga T, Nakano M, et al. Manually controlled targeted prostate biopsy with real-time fusion imaging of multiparametric magnetic resonance imaging and transrectal ultrasound: an early experience. Int J Urol. 2015; 22:173–178. PMID: 25316213.
8. Turkbey B, Pinto PA, Mani H, Bernardo M, Pang Y, McKinney YL, et al. Prostate cancer: value of multiparametric MR imaging at 3 T for detection--histopathologic correlation. Radiology. 2010; 255:89–99. PMID: 20308447.
9. Thompson JE, Moses D, Shnier R, Brenner P, Delprado W, Ponsky L, et al. Multiparametric magnetic resonance imaging guided diagnostic biopsy detects significant prostate cancer and could reduce unnecessary biopsies and over detection: a prospective study. J Urol. 2014; 192:67–74. PMID: 24518762.
10. Rud E, Klotz D, Rennesund K, Baco E, Berge V, Lien D, et al. Detection of the index tumour and tumour volume in prostate cancer using T2-weighted and diffusion-weighted magnetic resonance imaging (MRI) alone. BJU Int. 2014; 114:E32–E42. PMID: 24447606.
11. Arumainayagam N, Ahmed HU, Moore CM, Freeman A, Allen C, Sohaib SA, et al. Multiparametric MR imaging for detection of clinically significant prostate cancer: a validation cohort study with transperineal template prostate mapping as the reference standard. Radiology. 2013; 268:761–769. PMID: 23564713.
12. Mendhiratta N, Rosenkrantz AB, Meng X, Wysock JS, Fenstermaker M, Huang R, et al. Magnetic resonance imaging-ultrasound fusion targeted prostate biopsy in a consecutive cohort of men with no previous biopsy: reduction of over detection through improved risk stratification. J Urol. 2015; 194:1601–1606. PMID: 26100327.
13. Valerio M, Donaldson I, Emberton M, Ehdaie B, Hadaschik BA, Marks LS, et al. Detection of clinically significant prostate cancer using magnetic resonance imaging-ultrasound fusion targeted biopsy: a systematic review. Eur Urol. 2015; 68:8–19. PMID: 25454618.
14. National Comprehensive Cancer Network. NCCN Guidelines for Prostate Cancer Early Detection. Version 1. 2016 [Internet]. Philadelphia, PA: NCCN;2016. 2. 26. cited 2018 Oct 1. Available from:
15. Mottet N, Bellmunt J, Bolla M, Briers E, Cumberbatch MG, De Santis M, et al. EAU-ESTRO-SIOG guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol. 2017; 71:618–629. PMID: 27568654.
16. Bazinet M, Karakiewicz PI, Aprikian AG, Trudel C, Aronson S, Nachabé M, et al. Value of systematic transition zone biopsies in the early detection of prostate cancer. J Urol. 1996; 155:605–606. PMID: 8558670.
17. Fleshner NE, Fair WR. Indications for transition zone biopsy in the detection of prostatic carcinoma. J Urol. 1997; 157:556–558. PMID: 8996355.
18. Terris MK, Pham TQ, Issa MM, Kabalin JN. Routine transition zone and seminal vesicle biopsies in all patients undergoing transrectal ultrasound guided prostate biopsies are not indicated. J Urol. 1997; 157:204–206. PMID: 8976251.
19. Costa DN, Pedrosa I, Donato F Jr, Roehrborn CG, Rofsky NM. MR imaging-transrectal US fusion for targeted prostate biopsies: implications for diagnosis and clinical management. Radiographics. 2015; 35:696–708. PMID: 25786055.
20. Taira AV, Merrick GS, Galbreath RW, Andreini H, Taubenslag W, Curtis R, et al. Performance of transperineal template-guided mapping biopsy in detecting prostate cancer in the initial and repeat biopsy setting. Prostate Cancer Prostatic Dis. 2010; 13:71–77. PMID: 19786982.
21. Park YH, Lee JK, Jung JW, Lee BK, Lee S, Jeong SJ, et al. Prostate cancer detection rate in patients with fluctuating prostate-specific antigen levels on the repeat prostate biopsy. Prostate Int. 2014; 2:26–30. PMID: 24693531.
22. Carroll PR, Parsons JK, Andriole G, Bahnson RR, Castle EP, Catalona WJ, et al. NCCN guidelines insights: prostate cancer early detection, version 2.2016. J Natl Compr Canc Netw. 2016; 14:509–519. PMID: 27160230.
23. Baco E, Rud E, Eri LM, Moen G, Vlatkovic L, Svindland A, et al. A randomized controlled trial to assess and compare the outcomes of two-core prostate biopsy guided by fused magnetic resonance and transrectal ultrasound images and traditional 12-core systematic biopsy. Eur Urol. 2016; 69:149–156. PMID: 25862143.
24. Lawrentschuk N, Toi A, Lockwood GA, Evans A, Finelli A, O'malley M, et al. Operator is an independent predictor of detecting prostate cancer at transrectal ultrasound guided prostate biopsy. J Urol. 2009; 182:2659–2663. PMID: 19836804.
Full Text Links
  • ICU
export Copy
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: