Multi-parametric MRI (mp-MRI) has become a standard practice prior to prostate biopsy and the incorporation of ultrasound fusion allows precise and accurate targeted prostate biopsies (TPB). The role of random biopsies in the diagnosis of prostate cancer and clinically significant prostate cancer is yet to be determined. We aim to describe the value and significance of target and random biopsies with TPB in 464 patients at our institution

Between July 2019 and January 2024, 464 patients underwent trans-perineal MRI-targeted with ultrasound fusion using the Koelis Machine, and random prostate biopsies at AUBMC. The detection of prostate cancer (PCa) and clinically significant prostate cancer (csPCa) was compared between MRI-targeted biopsy (TB) and combined biopsy (CB).  Cancer severity was assessed using the grade group system, based on Gleason scores, with Grade Group 1 indicating low-grade cancer and Grade Groups 2–5 indicating higher grades. Clinically significant PCa (csPCa) was defined as Gleason score > 6 or Grade Group ≥ 2. McNemar test was used to compare Cancer detection between MRI-Targeted Biopsy and Combined Biopsy in addition to cancer detection in each Grade Group

PCa was diagnosed in 253/464 patients (54.5%) and HGPIN/ASAP in 11 patients (2.3%) by Targeted biopsy. Combining target with random biopsies led to cancer diagnosis in 264/464 patients (56.9%) with total increase as compared to TB alone of 11 patients (2.4%, P < 0.001), and an increase in csPCa detection by 7 patients (1.5%). The combined biopsy led to cancer upgrading to a higher-grade group vis-à-vis TB alone in 9 men (1.9% of all patients). The use of CB biopsy led to a higher detection of ISUP Grade Group 1 and 2 prostate cancer than target biopsy alone with p=0.046 and 0.025 respectively. There was no significant difference in cancer detection for other ISUP Grade Group. Comparing TB and CB according to the PIRADS score showed significant difference in cancer detection among patients with PIRADS 4 (p=0.008), and no significant difference in PIRADS 3 lesions possibly due to small sample size and no difference in PIRADS 5 lesions

benefit from random biopsies with a significant increase in detection rate of 4.2%. 
	Target	Combined	McNemar p-Value
	Count	Detection rate	Count	Detection rate	
Highest PIRADS score	3 (64)	8	12.5%	10	15.6%	0.5
	4 (190)	97	51.1%	105	55.3%	0.008
	5 (109)	93	85.3%	94	86.2%	1
	Total (463)	198	54.4%	209	57.4%	
Table 1: The relationship between PI-RADS score and cancer detection rate in target and combined biopsy.

CB seems to have no significant benefit in the diagnosis of prostate cancer in patients with a PIRADS 5 or PIRADS 3 lesion detected on mp-MRI. Patients with PIRADS 4 lesions may benefit from random biopsies with a significant increase in detection rate of 4.2%.