Is Saturation Biopsy Still a Viable Alternative to Fusion Biopsy in the Era of Multiparametric MRI? A Comparative Analysis in Patients With Prior Negative Biopsy

ABSTRACT Background We aimed to compare the diagnostic accuracy of transrectal ultrasound (TRUS)‐guided saturation biopsy (SB) and multiparametric MRI (mpMRI)‐TRUS fusion‐guided combined biopsy (CB) in patients with prior negative prostate biopsies. Methods We retrospectively analyzed data from 160 patients who underwent transrectal prostate biopsy between January 2014 and March 2021. All had at least one prior negative biopsy. 80 patients underwent SB with a 20‐core TRUS‐guided approach. The remaining 80 patients, with mpMRI‐detected PIRADS ≥ 3 lesions, underwent CB including 12‐core systematic plus 2–4 targeted cores per lesion. Prostate cancer and clinically significant prostate cancer (csPCa) detection rates, and clinical parameters were compared between groups. Results The groups had no statistically significant differences in baseline characteristics. The PCa detection rate was 20% in the CB group and 16.3% in the SB group ( p = 0.682). csPCa detection rates were also similar: 11.3% in the CB cohort and 7.5% in the SB cohort ( p = 0.589). Notably, the CB subgroup with PI‐RADS ≥ 4 lesions had a significantly higher csPCa detection rate (28.6%) than SB group (7.5%) ( p = 0.016). Patients diagnosed with PCa had significantly lower free PSA and free/total PSA ratios ( p < 0.05). Complication rates were low and similar in both groups. Conclusions CB demonstrates the highest diagnostic yield for detecting csPCa, particularly in patients with PI‐RADS ≥ 4 lesions. However, in resource‐limited settings lacking mpMRI, systematic saturation biopsy remains a viable, safe, and effective alternative. PSA derivatives may serve as complementary tools to refine biopsy decisions.