Triaging patients to primary biopsy or prostate MRI based on digital rectal examination improves the detection rate of TRUS biopsy and avoids unnecessary biopsies

The objective of this study is to describe how the use of digital rectal exam to triage patients to standard transrectal ultrasound (TRUS) biopsies or magnetic resonance imaging (MRI) then MRI fusion biopsies impacts cancer detection rates, departmental resources and the diagnostic journey. A retrospective analysis of all patients undergoing prostate biopsies in a 15-month period following the introduction of triage digital rectal exam (DRE) and MRI at Ayr University Hospital was conducted. MRI usage and patient journeys were also examined. A total of 95.5% of patients proceeding directly to TRUS had malignant histology and less than 1% required further investigation. Forty-nine per cent of patients who underwent triage MRI avoided biopsy and over one-third of patients with previously benign TRUS biopsies had clinically significant malignancy on MRI fusion biopsies. The pathway eliminated repeat TRUS biopsy and the number of biopsies a month decreased. MRI usage doubled and waiting times to diagnostic biopsy increased when compared to a one-stop diagnostic clinic. Triaging according to DRE avoided delays in cases of overt malignancy and increased the detection rate of standard TRUS. For those patients with a benign DRE, MRI enabled half to avoid biopsy. The increase in demand on MRI was mitigated, in part, by using a shorter detection protocol but institutions must be aware of the potential for delays to diagnosis.