Biopsy-free radical prostatectomy: a narrative review considering rationale, limitations, and current data

Abstract

Prostate biopsy prior to radical treatment for prostate cancer is a common practice worldwide to allow diagnosis, prognostication, and treatment planning. However, recent advances in prostate multiparametric magnetic resonance imaging (mpMRI) and prostate-specific membrane antigen (PSMA)-positron emission tomography (PET) have made the possibility of a "biopsy-free" radical prostatectomy, without prior biopsy, closer to reality than before. The biopsy-free approach serves to avoid investigation-related morbidity, health care resources, and time to definitive treatment, but is not without risk. Here we review the literature surrounding the rationale, limitations, and current data.

Keywords: Biopsy; Multiparametric magnetic resonance imaging; Prostate cancer; Prostate-specific membrane antigen positron emission tomography; Radical prostatectomy.

Fig. 1

Potentially suitable patient for biopsy-free radical prostatectomy, with imaging suspicious for high-risk prostate cancer. Panels A-B: mpMRI showing PIRADS 5 lesion with broad capsular abutment, Panels C-D PSMA-PET scan showing highly avid primary tumor (SUVmax 24) suspicious for seminal vesicle invasion.

Fig. 2

False-positive case demonstrating highly suspicious imaging (mpMRI, PSMA-PET) with no cancer on biopsy. Panels A-C: MRI images showing no suspicious lesion present (PIRADS 2); Panels D-E: PSMA-PET scan showing focal, high PSMA uptake (SUV max 17.3).