EURURO Vol. 71 No. 4

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performed the analysis on csPCa detection using the
definitions as applied in each original paper. Furthermore
several studies did not present a definition of csPCa, and
consequently did not report data on the detection of csPCa.
See for an overview of all included studies, baseline
characteristics, methodology applied for MRI imaging, and
biopsy procedures.
3.4. MRI outcome
An overall estimate of all studies (n = 20) reporting on the
number of patients with tumour suspicious findings on MRI
in patients with a clinical suspicion on PCa yielded 73%
(2225/3053) with MRI abnormalities. An overall estimate of
studies reporting on the number of patients with tumour
suspicious MRI abnormalities exclusively among patients
with no prior biopsies (n = 6) resulted in a yield of 68% (734/
1080), and a yield of 79% (567/716) exclusively among
patients with prior negative biopsies (n = 7).
3.5. MRI-GB versus TRUS-GB
3.5.1. Does MRI-GB result in a higher overall PCa detection rate
compared with TRUS-GB?
For this analysis we evaluated 25 studies that reported on
both MRI-GB (any technique) and TRUS-GB results
separately within the same population. The pooled
estimates of detection rates on a per patient basis
demonstrates that MRI-GB and TRUS-GB did not signifi-
cantly differ in overall PCa detection with a relative
sensitivity of 0.98 (95% confidence interval [CI]: 0.90–
1.07, sensitivity for MRI-GB of 0.81 [95% CI: 0.76–0.85], and
sensitivity for TRUS-GB of 0.83 [95% CI: 0.77–0.88]). In
other words MRI-GBmissed 19% of all cancers, while TRUS-
GB missed 17% ).
In addition to detection on a per patient basis,
14 included studies presented detection rates on a per
core basis for both MRI-GB and TRUS-GB. A pooled analysis
on detection rates of PCa per core demonstrates that MRI-
GB cores have a significant higher yield of PCa detection
compared with TRUS-GB biopsy cores (relative yield
3.91 [95% CI: 3.17–4.83], yield of MRI-GB 0.41 [95% CI
0.33–0.49], yield of TRUS-GB 0.10 [95% CI: 0.08–0.13]).
3.5.2. Does MRI-GB result in a higher detection rate of csPCa and a
lower detection rate of insignificant PCa compared with TRUS-GB?
For this analysis we evaluated 14 studies that reported on
the detection of csPCa for both MRI-GB and TRUS-GB
separately within the same population. A pooled analysis of
the detection rates of csPCa on a per patient basis,
demonstrates that MRI-GB detected significantly more
csPCa than TRUS-GB with a relative sensitivity of 1.16
(95% CI: 1.02–1.32, sensitivity for MRI-GB of 0.90 [95% CI:
0.85–0.94], sensitivity for TRUS-GB of 0.79 [95% CI: 0.68–
0.87)]. In other words MRI-GB missed 10% significant
cancers whilst TRUS-GB missed 21% ).
A pooled analysis of the detection rates of insignificant
PCa demonstrates that MRI-GB detected significantly less
insignificant PCa than TRUS-GB with a relative yield of
0.47 (95% CI: 0.35–0.63, yield for MRI-GB 0.07 [95% CI: 0.04–
0.10], yield for TRUS-GB of 0.14 [95% CI: 0.11–0.18]). In
other words TRUS-GB alone detected twice as many
clinically insignificant cancers as MRI-GB alone ).
3.5.3. Sensitivity analysis
When regarding the overall PCa detection rates exclusively
in publications with low risk of bias and low concerns
regarding applicability, which reported on TRUS-GB in
conjunction with MRI-GB within the same population
(n = 10), we found a relative sensitivity of 0.86 (95% CI:
0.74–0.99). When looking at csPCa detection rates in
publications with low risk of bias and low concerns
regarding applicability (n = 4), we found a relative sensitiv-
ity of 0.97 (95% CI: 0.71–1.33).
3.6. MRI-TB versus FUS-TB versus COG-TB
3.6.1. Which technique of targeting has the highest overall detection
rate of PCa?
Of the included studies that reported on the outcomes of
both MRI-GB and TRUS-GB within the same population,
seven used COG-TB to perform targeting (n = 712), 14 used
FUS-TB (n = 2817), and three used MRI-TB (n = 305). The
pooled sensitivity for COG-TB was 0.72 (95% CI: 0.62–0.81).
The pooled sensitivity for FUS-TB was 0.81 (95% CI: 0.75–
0.85). The pooled sensitivity for MRI-TB was 0.89 (95% CI:
0.78–0.95; A). Based on the above-mentioned pooled
sensitivities there is a significant ( p = 0.02) advantage of
using of MRI-TB compared with COG-TB for overall PCa
detection. There were no significant differences in the
performance of FUS-TB compared with MRI-TB (p = 0.13),
and FUS-TB compared with COG-TB (p = 0.11).
3.6.2. Which technique of targeting has the highest detection rate of
csPCa?
Of the included studies that reported on the detection rates
of csPCa of both MRI-GB and TRUS-GB within the same
population, three used COG-TB to perform targeting
(n = 220), eight used FUS-TB (n = 2114), and two used
MRI-TB (n = 163). The pooled sensitivity for csPCa for
COG-TB was 0.86 (95% CI: 0.69–0.94). The pooled sensitivity
for FUS-TB was 0.89 (95% CI: 0.82–0.93). The pooled
sensitivity for MRI-TB was 0.92 (95% CI: 0.76–0.98;
B). Based on the above-mentioned pooled sensitivities
there was no significant advantage of usage of any one
technique of MRI-GB for the detection of csPCa; MRI-TB
versus FUS-TB (p = 0.60), MRI-TB versus COG-TB (p = 0.42),
FUS-TB versus COG-TB (p = 0.62).
3.7. Discussion
3.7.1. Summary of findings
The paradigm on biopsy strategies in men with increased
risk for PCa is shifting, and the optimal biopsy strategy is yet
to be determined. The optimal biopsy technique presum-
ably has a near 100% detection rate of csPCa, while
simultaneously having a low detection rate of clinically
insignificant PCa.
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