Are template prostate biopsies still required in patients with high‐risk PI‐RADS lesions? A retrospective study of 470 patients

Abstract Objectives To determine the incremental diagnostic yield of systematic template sampling during transperineal prostate biopsy (TPPB) in biopsy‐naïve men and to identify patient subgroups where systematic biopsy might be safely omitted. Patients and Methods We retrospectively analysed 470 consecutive biopsy‐naïve men with PI‐RADS 3–5 lesions on multiparametric MRI who underwent combined MRI‐targeted and systematic template TPPB between January 2022 and May 2026 at a single institution. Clinically significant prostate cancer (csPCa) was defined as ISUP grade group 2 or higher. The primary outcome was csPCa detected on template biopsy in men with non‐significant disease (ISUP < 2) on targeted biopsy. Results Overall, csPCa was detected in 356/470 men (75.7%). Systematic template biopsy identified csPCa missed by targeted biopsy in 10/470 men (2.1%, 95% CI 1.0%–3.9%), representing 2.8% of all csPCa diagnoses. Smaller index lesion size on MRI was the only statistically significant predictor of csPCa missed by targeted biopsy (OR 0.50 per 5 mm increase, 95% CI 0.28–0.90, p = 0.021). In subgroup analysis cross‐tabulating PI‐RADS category and PSA density (PSAD), template biopsy provided zero incremental yield in patients with PI‐RADS 5 lesions and a PSAD > 0.20 ng/mL 2 (0.0%, one‐sided 95% upper bound 2.5%). The highest incremental yield was observed in men with PI‐RADS 4 lesions (3.7%, 95% CI 1.7%–7.0%). Conclusions In this biopsy‐naïve cohort of men undergoing combined MRI‐targeted and template TPPB, systematic template biopsy provided a small incremental diagnostic yield for csPCa (2.1%) overall, with no added value in men with PI‐RADS 5 lesions and a PSAD > 0.20 ng/mL 2 . A risk stratified approach to systemic sampling in these men may be considered. Validation in larger, multicentre cohorts is warranted before these findings can be incorporated into future guideline recommendations.