How to cite: Coakley F. State of the Art and Future Directions in Prostate Biopsies: Imaging Perspective. Grand Rounds in Urology. September 15, 2025. Accessed Mar 2026. https://grandroundsinurology.com/state-of-the-art-and-future-directions-in-prostate-biopsies-imaging-perspective/
Summary
Fergus Coakley, MD, Professor and Chair of Diagnostic Radiology, Oregon Health and Science University, Portland, Oregon, emphasizes the paradigm shift in prostate cancer diagnostics. Once reserved for staging after TRUS biopsy, MRI is now increasingly used up front for lesion localization and biopsy targeting.
Dr. Coakley warns that challenges remain. MRI quality and interpretation vary widely between community and specialty centers, influencing cancer detection. He also illustrates limitations of fusion biopsy, particularly registration errors caused by prostate deformation during probe movement. He reports that in-bore MRI-guided biopsy has demonstrated higher positivity rates than fusion.
Dr. Coakley examines the rationale for targeted-only biopsy. While off-target systematic sampling sometimes detects additional cancers (~6–7% of cases), many are small and clinically unimportant. Moreover, more biopsy cores increase risks such as urinary retention and biopsy-related mortality, though rare (~1/1000), is non-trivial.
Future directions include standardization efforts, possible accreditation models (akin to breast imaging’s BI-RADS and MQSA), and greater emphasis on imaging-pathology correlation. Dr. Coakley argues that radiologists who perform in-bore biopsies gain unique insights into patient experience and diagnostic responsibility, further refining their interpretation skills.
The Global Summit on Precision Diagnosis and Treatment of Prostate Cancer is a unique multi-disciplinary forum organized to inform the key health care stakeholders about the emerging advances in clinical case and research and create a consensus-based vision for the future of precision care and educational and research strategy for its realization. The mission of the Summit is to fill the currently existing gap between the key experts of in vivo imaging, the world authorities in the in vitro fluid- and tissue-based molecular diagnostics, including genomics, and thought leaders in the development of novel observation strategies (e.g., active surveillance, or AS) and therapeutic interventions.
ABOUT THE AUTHOR
Fergus Coakley, MD, is the Chair of Diagnostic Radiology, and a Professor of Diagnostic Radiology for the School of Medicine at Oregon Health & Science University, in Portland, Oregon. He joined OHSU in August 2012 from the University of California, San Francisco (UCSF) where he was a Professor in Residence in the Department of Radiology and Biomedical Imaging in the UCSF School of Medicine. He was also Chief of the Abdominal Imaging Section and Vice Chair for Clinical Services in the Department of Radiology and Biomedical Imaging.
