Abstract
BACKGROUND: This study aims to evaluate whether MRI-US-guided FB leads to improved diagnostic accuracy compared to SB and whether SB remains necessary for the detection of csPCa, further assessing whether the TP or TR biopsy approach influences outcomes. METHODS: In this retrospective single-center study, 851patients with PI-RADS ≥ 3 lesions on mpMRI underwent combined FB and SB between June 2019 and November 2024. The highest ISUP Grade Group per patient was compared between methods. Discordant findings were analyzed, and csPCa detection rates were compared between TP and TR approaches. RESULTS: FB detected higher ISUP-GG values in 70.9% of discordant cases. csPCa (ISUP-GG 2–5) was identified in 42.2% of patients with FB compared to 28.5% with SB (p < 0.001), while rates of ciPCa were similar. FB missed PCa (ISUP-GG 1–5) in 6.5% of patients. TP biopsy demonstrated higher csPCa detection than TR biopsy (50.1% vs. 43.0%, p = 0.038). CONCLUSION: FB significantly improves detection of csPCa compared to SB. However, FB cannot yet replace SB as it would miss total PCa in 6.5% of patients, thus the use of both methods together provides the most reliable diagnosis. Further TP approach provides higher csPCa detection and should be preferred when feasible. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12894-026-02113-5.