The definitive diagnosis of prostate cancer, the most common cancer in men, is made by biopsy. Prostate cancer is a very common cancer that increases with age and peaks in the 80s, but as common as it is, it is a slow-growing cancer that is not very lethal. Nearly half of these common prostate cancers are clinically insignificant and the rest are clinically important cancers that require serious follow-up and treatment. Nowadays, multiparametric prostate MRI is performed first for patients with suspicion of prostate cancer, and the suspicious areas detected in the MRI are evaluated by PI-RADS and the lesions are categorized (PI-RADS 1-5), and a biopsy can be planned for areas with category 3, 4 and 5 lesions. Biopsies are taken from these high-risk lesions seen in multiparametric prostate MRI using the fission technique.
Prostate biopsy indications: The only way to diagnose prostate cancer in men with a high risk of prostate cancer is to perform a prostate biopsy. Those with high blood PSA (Prostate specific antigen) level or free/total ratio below 20%, Those with suspicious prostate lesion or hardness in digital rectal examination, Category 3 in prostate PI-RADS evaluation in Multiparametric prostate MRI taken due to suspicion of prostate cancer, Those with areas 4 and 5, those at risk of cancer in genetic tests, or those with more than 2 men in their family with prostate cancer are candidates for prostate biopsy.
Biopsy preparation: The most important complications in prostate biosis are infection and bleeding. Therefore, before prostate biopsy, which is an invasive procedure, it is necessary to ensure that the urinalysis and urine culture are clean and normal. Since the biopsy is performed transrectally, in accordance with the international protocol, antibiotics must be started one day before the biopsy and antibiotics must be continued for three days after the biopsy. Again, in order to cleanse the bowel before the biopsy, enema is applied 1-2 hours before the procedure. In addition, due to the risk of bleeding, the blood thinners (anticoagulants) used, if any, are stopped for a while and, if necessary, some short-acting anticoagulants can be started. Prostate biopsy can be performed under local anesthesia or general anesthesia (especially in fusion biopsies). It is preferred that patients fast for 6 hours beforehand.
PROSTATE BIOPSY TYPES: Prostate biopsy is currently divided into 2 main groups. These are classical prostate biopsy and fusion prostate biopsy.
1-Classical prostate biopsy (systematic biopsy): This type of prostate biopsy is classically performed under the guidance of transrectal ultrasonography in areas close to the peripheral zone where cancer is frequently seen in the prostate. It refers to the biopsy taken from 12 quadrants on the right and left side, systematically, regardless of target, and is still very commonly performed by a urologist. Before this type of biopsy, a biopsy decision is made after multiparametric prostate MRI and other examinations are performed.
2-Fusion biopsy: Multiparametric prostate MRI is performed on patients before the biopsy. From the images in the MRI, areas suspicious for high-risk and clinically important prostate cancer (PIRADS Category 3, 4 and so on) are determined and marked by the radiologist on the MRI images, and then the second stage is started. At this stage, an ultrasound probe is placed in the perineum or rectum region, preferably under general anesthesia or sedation, and ultrasound and MRI images are matched, and a sufficient number and quantity of biopsies are performed from these foci with millimetric precision. After the fusion biopsy is performed, systemic biopsy can be performed in the same session, if desired.
Comparison of fusion and classical prostate biopsy: In fact, they should not be considered as alternative methods to each other. While biopsy samples are taken from systematic standard areas (close to the peripheral zone) under the guidance of transrectal ultrasound with the classical method, fusion biopsy is multiparametric. High-risk areas on MRI are marked and matched with real-time ultrasound images, directing the biopsy needle directly to foci of suspected cancer.
FUSION PROSTATE BIOPSY APPLICATION: Prostate biopsy, urology and radiologists together. After the radiologist marks areas suspicious for cancer on MRI images  ; These images are uploaded to the system of the fusion prostate biopsy device and the images are matched and biopsies are performed from these areas with targeted millimetric precision via transrectal or perineal route
There are 3 different techniques of fusion biopsy:
1- Biopsy under MRI: A biopsy can be taken from high-risk areas detected by MRI with great accuracy. It is possible to perform classical-systematic prostate biopsy not only from the areas determined by MRI but also in the same session.
2-Cognitive MRI biopsy:It is a method of taking biopsy samples from the determined areas under transrectal USG guidance, keeping in mind the specialist who will perform the prostate biopsy in the high-risk areas of the MRI.
3-Software-assisted real MRI-Ultrasound Fusion biopsy: After marking areas suspicious for cancer on the MRI images, these images are uploaded to the system of the fusion prostate biopsy device and the images are matched by the software, the ultrasound probe When it is moved around the prostate, the fusion software shifts the overlapped MR image accordingly and a detailed 3D ultrasonography + MR image is provided. In the combined image, the biopsy needles are directed to the lesion to be sampled with millimetric precision towards the target and a sufficient number of samples are made.
IN CONCLUSION:
It is extremely important to perform multiparametric MRI examination before biopsy in patients with clinical suspicion of prostate cancer.
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