Pathologic prostate cancer grade concordance among high-resolution micro-ultrasound, systematic transrectal ultrasound and MRI fusion biopsy

•For image guided prostate bipsy, MRI-microUS and MRI-TRUS fusion biopsy techniques were associated with similar rates of GG upgrade on final pathology after radical prostatectomy.•Both techniques had a lower rate of GG upgrade compared to microUS only biopsy or TRUS only biopsy.•There was no difference between GG upgrade between microUS only guided biopsy and TRUS biopsy.•In a moderately sized cohort this is the first to investigate pathologic concordance in MRI-microUS fusion compared to MRI-TRUS fusion biopsy. Comparative studies among biopsy strategies have not been conducted evaluating pathologic concordance at radical prostatectomy(RP), especially with novel micro-ultrasound (micro-US) image-guided biopsy. A retrospective study among patients with PCa who underwent RP following TRUS, MRI-TRUS fusion, microUS, or MRI-microUS fusion biopsy in a multi-site single institution. We compared GG-upgrade from biopsy to RP based on highest GG in any biopsy core and examined clinical/pathologic factors associated with pathologic upgrading using descriptive statistics, and multivariable logistic-regression analysis. 429 patients between 1/2021 and 6/2023 including 10 (25.6%) who underwent systematic TRUS, 237 (55.2%) MRI-TRUS, 67 (15.6%) MRI-microUS and 15 (3.5%) micoUS-alone biopsy prior to RP. 78 (18.2%) were upgraded on final pathology (TRUS 31 (28.2%), MRI-TRUS 31 (13.1%), MRI-microUS 10 (14.9%), microUS: 6 (40%)) and 99 downgraded. 14 (3.5%) experienced a major upgrade (≥2 GG increase). On multivariable-analysis both MRI-TRUS (odds ratio, OR: 0.31,95% CI:0.17–0.56, P < 0.001) and MRI-microUS (OR: 0.43,95%CI: 0.19–0.98, P = 0.044) were associated with lower odds pathological-upgrade compared with TRUS biopsy alone. No significant differences in the odds of upgrade between TRUS and microUS alone (P > 0.05), or between MRI-microUS and MRI-TRUS(P = 0.696) on pairwise comparisons. MRI-microUS was associated with lower upgrade compared with microUS (OR: 0.26,95% CI:0.08–0.90, P = 0.034). No difference among the biopsy strategies in pathologic downgrading or overall GG concordance. Limitations include retrospective analysis, inter-clinician experience and lesion selection in varying biopsy techniques. Both MRI-microUS and MRI-TRUS fusion were associated with similarly improved GG concordance compared with TRUS biopsy. No significant differences between microUS-alone and TRUS or between MRI-microUS and MRI-TRUS fusion approaches, may suggest similar accuracy perfor