Prostate biopsy has been standardised nowhere across patient selection, tools, technique and sampling scheme, and the variation feeds straight into treatment planning. ProBIOPSY put 34 international experts through three modified Delphi rounds over 96, 99 and 112 statements grouped into 36 stems, informed by a systematic review, with consensus assessed by a modified RAND appropriateness method. Twenty-nine of the 36 stems reached consensus.
Three conclusions matter in clinic. Biparametric MRI is endorsed alongside multiparametric within the diagnostic pathway, provided image quality is adequate — a meaningful concession for services where contrast, scanner time and cost limit throughput, and one that puts the burden on demonstrating quality rather than on running every sequence. Targeted plus perilesional sampling was harmonised and judged sufficient for most aspects of local treatment planning. And the exception is stated: additional contralateral sampling still appears necessary for specific indications, focal therapy candidate selection in particular.
The change to make is to stop treating the biopsy scheme as a fixed departmental protocol. The panel's own conclusion is that no single approach gives complete information for every decision, so the sampling should follow the question — a man heading for surveillance or radical treatment does not need what a focal therapy candidate needs. That requires the indication to be known before the biopsy is booked, which is an organisational change more than a technical one. Seven stems failed to reach consensus, and the panel notes imbalances in specialty representation, so this is a framework to adopt with local judgement rather than a rulebook.
- Decide the clinical question before booking the biopsy — the sampling scheme should follow it.
- Add contralateral sampling where focal therapy is being considered; targeted plus perilesional is not enough there.
- Biparametric MRI is acceptable in the pathway where image quality is demonstrably adequate.
- Use targeted plus perilesional as the default scheme for most treatment planning.
- Seven of 36 stems reached no consensus — this is a framework, not a rulebook.
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