Optimization of prostate biopsy in patients considered for active surveillance. The role of the confirmatory biopsy and transperineal techniques

To review the pathological criteria used to select patients for active surveillance, the optimization of biopsies and the role of confirmatory biopsy and of the transperineal approach. A bibliographic revision of the last years about active surveillance in prostate cancer as well as prostate biopsy, optimal rebiopsy protocols and transperineal approach has been carried out. Misclassification of insignificant disease based on pathological criteria of the first standard biopsy range from 20% to 30% of men. It is likely that many patients who ultimately progress on active surveillance had at the time of diagnosis more advanced disease that was missed by transrectal ultrasound (TRUS) biopsy. This is the main cause of progression on initial follow-up biopsy within 1 year of starting active surveillance. Although the role of immediate prostate rebiopsy after the diagnosis of low-risk prostate cancer and has not been well described, repeat biopsy before the initiation of AS performed shortly after diagnosis (6 months) identifies most patients who harbor high grade or more extensive cancers that may not be appropriate for a surveillance strategy. PSA, PSAD, and number of cores at initial diagnosis are not helpful in predicting misclassification of AS eligibility. The role of MRI for AS remains unclear and the technique of MRI/US fusion biopsy still lacks consensus on a standardized procedure. Patients considering active surveillance should undergo immediate confirmatory biopsy within 6 months to decrease the risk of substantially underestimating cancer size and grade, even in patients with strict criteria in the initial biopsy and subsequently, to better assess the risk of progression. In this way, most protocols of AS recommend performing volume-based biopsies in the confirmatory procedure. Perhaps, an extensive transperineal template-guided mapping biopsy (TTMB) procedure could more accurately identify those men with occult significant disease. Due to confirmatory biopsy identifies a patient group that is unlikely to progress during the first 5 to 10 years of AS the need of intensive biopsy schedule during follow-up of patients undergoing active surveillance might be reduced.