Active surveillance: transperineal biopsies and evaluation of multi-parametric magnetic resonance imaging


  • Zubair Bhat Department of Urology, Medway NHS Trust Gillingham, Kent, United Kingdom
  • Arshad Bhat Department of Urology, Medway NHS Trust Gillingham, Kent, United Kingdom
  • Jayasimha Abbaraju Department of Urology, Darent Valley Hospital, Kent, England, United Kingdom
  • Mudassir Wani Department of Urology, Medway NHS Trust Gillingham, Kent, United Kingdom
  • Tahir Bhat Department of Urology, Medway NHS Trust Gillingham, Kent, United Kingdom
  • Shameer Deen Department of Urology, Princess Royal University Hospital King’s College, London, United Kingdom



Prostate cancer, Active surveillance, Transperineal biopsy


Background: Active surveillance has emerged as an acceptable choice for low-risk prostate cancer patients and is defined as a treatment strategy of close monitoring through PSA, digital rectal examination, imaging and prostate biopsy, with conversion to curative treatment if progression occurs. An ideal tool for risk-stratification would detect aggressive cancers and exclude such men from taking up active surveillance in the first place.

Methods: We retrospectively reviewed patients who underwent transperineal template biopsies from January 2016 till December 2018. All the patients had been classified as low grade prostate cancer after conventional trans-rectal ultrasound guided biopsy and enrolled in AS after discussion in hospital MDM. As per NICE guidelines all patients underwent multi-parametric magnetic resonance imaging (MRI). All suspicious lesions were assigned a PIRAD score; this was followed by Trans-perineal prostate biopsy. 142 patients were on active surveillance and underwent mapping transperineal template biopsies and cognitive target biopsies. 130 of them had multi-parametric MRI prior to the biopsies.

Results: In 52% of cases the histology was upgraded. In 34 (24%) the cancer was upgraded to Gleason 3+4 and 39 (28%) it was upgraded to scores higher than Gleason 3+4. Only 64 (45%) patients continued on active surveillance post-template biopsies due to significant upgrading of histology.

Conclusions: We advocate combination of MRI and an early transperineal template guided prostatic biopsies for intermediate risk prostate cancer, multiple core involvement, higher PIRAD grades and suspicious prostate on digital rectal examination in order to re-stage the initial disease and provide better safety for this cohort of patients.


Schroder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320.

Wilt TJ, Brawer MK, Jones KM, Barry MJ, Aronson WJ, Fox S, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med. 2012;367:203-13.

Bill-Axelson A, Holmberg L, Ruutu M, Garmo H, Stark JR, Busch C, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2011;364:1708-17.

Klotz L, Zhang L, Lam A, Lam A, Nam R, Mamedov A, et al. Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J Clin Oncol. 2010;28:126-31.

Beauval JB, Ploussard G, Soulie M. Pathologic findings in radical prostatectomy specimens from patients eligible for active surveillance with highly selective criteria: a multicenter study. Urol. 2012;80:656-60.

Mullins JK, Han M, Pierorazio PM, Partin AW, Carter HB. Radical prostatectomy outcome in men 65 years old or older with low risk prostate cancer. J Urol. 2012;187:1620-5.

Adamy A, Yee DS, Matsushita K, Maschino A, Cronin A, Vickers A, et al. Role of prostate specific antigen and immediate confirmatory biopsy in predicting progression during active surveillance for low risk prostate cancer. J Urol. 2011;185:477-82.

Bott SR, Henderson A, Halls JE, Montgomery BS, LaingR, Langley SE. Extensive transperineal template biopsiesof prostate: modified technique and results. Urol. 2006;68:1037-41.

Bott SR, Henderson A, Parkinson MC, Langley SE. Setting upa prostate câncer database: experiences on how to get outmore than you put in. BJU Int. 2003;92:665-6.

Prostate cancer: diagnosis and management. Clinical guideline [CG175]. National Institute for Health and Care Excellence; 2014.

Choo R, Klotz L, Danjoux C, Morton GC, DeBoer G, Szumacher E, et al. Feasibility study: watchful waiting for localized low to intermediate grade prostate carcinoma with selective delayed intervention based on prostate specific antigen, histological and/or clinical progression. J Urol. 2002;167:1664-9.

Parker C. Active surveillance: an individualized approach to early prostate cancer. BJU Int. 2003;92:2-3.

Van den Bergh RC, Albertsen PC, Bangma CH, Freedland SJ, Graefen M, Vickers A, et al. Timing of curative treatment for prostate cancer: a systematic review. Eur Urol. 2013;64:204-15.

van den Bergh RC, Roemeling S, Roobol MJ, Roobol W, Schröder FH, Bangma CH. Prospective validation of active surveillance in prostate cancer: the PRIAS study. Eur Urol. 2007;52(6):1560-3.

Bul M, van den Bergh RC, Zhu X, Zhu X, Rannikko A, Vasarainen H, et al. Outcomes of initially expectantly managed patients with low or intermediate risk screendetected localized prostate cancer. BJU Int. 2012;110:1672-7.

Godtman RA, Holmberg E, Khatami A, Stranne J, Hugosson J. Outcome following active surveillance of men with screen‐detected prostate cancer. Results from the Goteborg randomised population‐based prostate cancer screening trial. Eur Urol. 2013;63:101-7.

Thomsen FB, Brasso K, Klotz LH, Røder MA, Berg KD, Iversen P. Active surveillance for clinically localized prostate cancer-a systematic review. J Surg Oncol. 2014;109:830.

Loeb S, Bruinsma SM, Nicholson J, Briganti A, Pickles T, Kakehi Y, et al. Active surveillance for prostate cancer: a systematic review of clinicopathological variables and biomarkers for risk stratification. Eur Urol. 2015;67:619.

Heidenreich A, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, et al.: EAU guidelines on prostate cancer. Part 1: Screening, diagnosis, and treatment of clinically localised disease. Eur Urol. 2011;59:61-71.

Mohler J, Bahnson RR, Boston B, Busby JE, D'Amico A, Eastham JA, et al. NCCN clinical practice guidelines in oncology: Prostate cancer. J Natl Compr Canc Netw. 2010;8:162-200.

Haffner J, Lemaitre L, Puech P Haber GP, Leroy X, Jones JS, et al. Role of magnetic resonance imaging before initial biopsy: Comparison of magnetic resonance imaging‐targeted and systematic biopsy for significant prostate cancer detection. BJU Int. 2011;108:e171-8.

Vargas HA, Akin O, Afaq A, Goldman D, Zheng J, Moskowitz CS, et al. Magnetic resonance imaging for predicting prostate biopsy findings in patients considered for active surveillance of clinically low risk prostate cancer. J Urol. 2012;188:1732-8.

Somford DM, Hamoen EH, Futterer JJ, van Basten JP, van de Kaa CA, Vreuls W, et al. The predictive value of endorectal 3 tesla multiparametric magnetic resonance imaging for extraprostatic extension in patients with low, intermediate and high risk prostate cancer. J Urol. 2013;190:1728-34.

O’Brien MF, Cronin AM, Fearn PA, Smith B, Stasi J, Guillonneau B, et al. Pretreatment prostatespecific antigen (PSA) velocity and doubling time are associated with outcome but neither improves prediction of outcome beyond pretreatment PSA alone in patients treated with radical prostatectomy. J Clin Oncol. 2009;27:3591-7.

Ross AE, Loeb S, Landis P, Partin AW, Epstein JI, Kettermann A, et al.: Prostate‐specific antigen kinetics during follow‐up are an unreliable trigger for intervention in a prostate cancer surveillance program. J Clin Oncol. 2010;28:2810-6.

Loeb S, Metter EJ, Kan D, Catalona WJ. Prostate‐specific antigen velocity (PSAV) risk count improves the specificity of screening for clinically significant prostate cancer. BJU Int. 2012;109:508-13.

Thomsen FB, Roder MA, Hvarness H, Christensen IJ, Brasso K, Røder MA. Active surveillance for patients with low‐risk prostate cancer: How does PSA doubling time affect the risk of histo‐pathological progression at re‐biopsy? Urol Suppl. 2012;80:1-35.

Thomsen FB, Christensen IJ, Brasso K, Røder MA, Iversen P. PSA doubling time as a progression criterion in an active surveillance programme for patients with localised prostate cancer. BJU Int. 2013; 113(5b):e98-105.

Ischia JJ, Pang CY, Tay YK, Suen CF, Aw HC, Frydenberg M, et al. Active surveillance for prostate cancer: An Australian experience. BJU Int. 2012;109:40-3.

Kasivisvanathan V, Dufour R, Moore CM, Ahmed HU, Abd-Alazeez M, Charman SC, et al. Transperineal magnetic resonance image targeted prostate biopsy versus transperineal template prostate biopsy in the detection of clinically significant prostate cancer. J Urol. 2013;189:860-6.

Miyagawa T, Ishikawa S, Kimura T , Suetomi T, Tsutsumi M, Irie T, et al. Realtimevirtual sonography for navigation during targetedprostate biopsy using magnetic resonanceimaging data. Int J Urol. 2010;17:855.

Ayres BE, Montgomery BSI, Barber NJ, Pereira N, Langley SE, Denham P, et al. The role of transperineal template prostate biopsies in restaging men with prostate cancer managed by active surveillance. BJU Int. 2012;109(8):1170-6.

Philippou Y, Raja H, Gnanapragasam VJ. Active surveillance of prostate cancer: a questionnaire survey of urologists, clinical oncologists and urology nurse specialists across three cancer networks in the United Kingdom. BMC Urol. 2015;15:52.

Tosoian JJ, Trock BJ, Landis P, Feng Z, Epstein JI, Partin AW, et al. Active surveillance program for prostate cancer: An update of the Johns Hopkins experience. J Clin Oncol. 2011;29:2185-90.

Ercole B, Marietti SR, Fine J, Albertsen PC. Outcomes following active surveillance of men with localized prostate cancer diagnosed in the prostate specific antigen era. J Urol. 2008;180:1336-9.

Dall’Era MA, Konety BR, Cowan JE, Shinohara K, Stauf F, Cooperberg MR, et al. Active surveillance for the management of prostate cancer in a contemporary cohort. Cancer. 2008;112:2664-70.

Soloway MS, Soloway CT, Eldefrawy A, Acosta K, Kava B, Manoharan M. Careful selection and close monitoring of low‐risk prostate cancer patients on active surveillance minimizes the need for treatment. Eur Urol. 2010;58:831-5.

Thomsen FB, Roder MA, Hvarness H, Iversen P, Brasso K. Active surveillance can reduce overtreatment in patients with low‐risk prostate cancer. Dan Med J. 2013;60:A4575.

Selvadurai ED, Singhera M, Thomas K, Mohammed K, Woode-Amissah R, Horwich A, et al. Medium‐term outcomes of active surveillance for localised prostate cancer. Eur Urol. 2013;64:981-7.






Original Research Articles