European Urology Oncology Magnetic Resonance Imaging–guided In-bore and Magnetic Resonance Imaging- transrectal Ultrasound Fusion Targeted Prostate Biopsies: An Adjusted Comparison of Clinically Significant Prostate Cancer Detection Rate  Daniel N. Costa, Kenneth Goldberg, Alberto Diaz de Leon, Yair Lotan, Yin Xi, Muhammad Aziz, Yuval Freifeld, Vitaly Margulis, Ganesh Raj, Claus G. Roehrborn, Brad Hornberger, Neil Desai, Aditya Bagrodia, Franto Francis, Ivan Pedrosa, Jeffrey A. Cadeddu  European Urology Oncology  DOI: 10.1016/j.euo.2018.08.022 Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 1 Eligibility and patient cohorts. n=number of men; MRI=multiparametric magnetic resonance imaging; PCa=prostate cancer. European Urology Oncology DOI: (10.1016/j.euo.2018.08.022) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 2 Steps of an in-bore biopsy. In a 69-yr-old man with previous negative 12-core biopsy and PSA of 10ng/ml, multiparametric MRI revealed a 15mm PI-RADS 5 lesion in the right apex peripheral zone. (A) The in-bore biopsy begins with images to re-identify the known lesion (arrow), (B) then the region of interest is chosen (green circle), and (C) the targeting software indicates the changes necessary to move the needle guide to a position aligned with the suspicious area. (D) After needle guide is repositioned, images along the long axis of the needle guide are obtained to verify the needle guide (arrows) and lesion (yellow circle) alignment. (E) Finally, biopsy is performed and images are obtained with the needle in place to confirm adequate sampling. PCa grade group 2 was detected in three of three cores, with up to 100% of the core length containing tumor. MRI=magnetic resonance imaging; PI-RADS=Prostate Imaging Reporting and Data System; PSA=prostate-specific antigen. European Urology Oncology DOI: (10.1016/j.euo.2018.08.022) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 3 Per-patient biopsy yields according to PI-RADS score and biopsy strategy adjusted for confounding variables using propensity score weighting. Nonadjusted data are shown in Table 1. ISUP=International Society of Urological Pathology; PI-RADS=Prostate Imaging and Reporting Data System. European Urology Oncology DOI: (10.1016/j.euo.2018.08.022) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 4 Precise needle-lesion location verification offered by in-bore biopsy. (A and B) A 65-year-old biopsy-naïve man with PSA of 5.6ng/ml and a 5mm PI-RADS score 4 lesion in the right mid gland peripheral zone. (A) Prefiring image shows needle guide (yellow arrows) properly aligned with the lesion (white arrow), (B) which is properly sampled by the core biopsy needle. PCa grade group 3 was detected in three of three cores with up to 50% of the core length containing tumor. (C–E) A 66-yr-old man with PSA of 3.7ng/ml, previous negative saturation biopsy, and a 10mm PI-RADS score 4 lesion in the left base transition zone. (C) Prefiring images confirm proper alignment of the needle guide and the lesion (white arrow); however, (D) needle insertion results in anatomical changes, and sampled area does not correspond to the suspicious region. (E) Such unexpected needle trajectory is compensated for on the subsequent core, and adequate sampling is confirmed. Core obtained in Figure 4D was negative and that in Figure 4E revealed grade group 2 PCa in 70% of the core length. PCa=prostate cancer; PI-RADS=Prostate Imaging and Reporting Data System; PSA=prostate-specific antigen. European Urology Oncology DOI: (10.1016/j.euo.2018.08.022) Copyright © 2018 European Association of Urology Terms and Conditions