Table 2 Summary of recommendations for imaging and biopsy in focal therapy.

de la Rosette et al. [7]

• Candidates for FT should ideally undergo transperineal template-mapping biopsies, although a state-of-the-art multifunctional MRI with TRUS biopsy at expert centers may be acceptable

Ahmed et al. [32]

• mpMRI and transperineal prostate mapping biopsy can improve PCa care and risk stratification before FT.

Muller et al. [31]

• mpMRI is the optimum approach to achieve the objectives needed for FT, if made on a high-quality machine (3 T with/without endorectal coil or 1.5 T with endorectal coil) and judged by an experienced radiologist.

• Structured and standardized reporting of prostate MRI is paramount.

• State of the art mpMRI is capable of localizing small tumors for focal therapy.

• State of the art mpMRI is the technique of choice for follow-up of focal ablation.

Donaldson et al. [9]

• MRI-targeted or template-mapping biopsy should be used to plan treatment.

Scheltema et al. [14]

• mpMRI should be performed in patients with prior negative biopsies if clinical suspicion remains.

• mpMRI should not be performed as stand-alone diagnostic tool or with mpMRI-targeted biopsies only.

• mpMRI should be performed following standard biopsy-based PCa diagnosis in both the planning and follow-up of FT.

• MRI-TRUS fusion is the recommended technique to perform biopsies following mpMRI.

• Systematic biopsies are still required for FT planning in biopsy-naïve patients and patients with residual PCa after FT.

• Repeat biopsies should be taken during the follow-up of FT.

• The final decision to perform FT should be based on histopathology and not be based on mpMRI results alone.

• Only in expert centers, where the quality is assured and own results are monitored, mpMRI may be performed in all patients suspected of PCa.

• Only in expert centers, deferral of repeat biopsy may be considered in case of a negative mpMRI.

• It should be our goal to guarantee high-quality mpMRI throughout the urological community before implementing it as standard of care.

Tay et al. [10]

▪ mpMRI is a standard imaging tool to select patients for FT. 

    • mpMRI is essential particularly in the setting of targeted/lesional ablation. 

    • mpMRI is preferred whenever possible when FT is planned (core group)

▪ In the presence of an mpMRI-suspicious lesion (PIRADSv2 4/5), histological confirmation is necessary prior to treatment with FT.

▪ MRI–TRUS fusion biopsy is adequate in assessing an mpMRI lesion prior to FT. 

    • VET/cognitive fusion biopsy can be considered adequate in expert hands (core group)

▪ Systematic biopsies remain necessary to assess mpMRI-negative areas prior to treating a histologically confirmed mpMRI lesion.

▪ Where mpMRI is unavailable or contraindicated, 12 core TRUS biopsy alone is insufficient for patient selection for FT.

van Luijtelaar et al. [11]

• Patients who require targeted ablation of specific focus with in-bore transperineal or transrectal technique using mpMRI as the standard imaging tool.

• Will have systematic biopsies as necessary.

Tan et al. [13]

• mpMRI/US-guided fusion biopsy and a 12-core systematic biopsy is recommended for men on active surveillance prior to considering focal therapy.

• If unable to undergo mpMRI, patients will require a 3D mapping biopsy of the prostate to determine if they are a candidate for focal therapy.

• No metastatic workup is usually required prior to considering focal therapy

Borkowetz et al. [12]

▪ Patients considering FT should undergo mpMRI, mpMRI fusion biopsy, and systematic biopsy.

▪ If MRI fusion biopsy is not possible, a template-based biopsy may be considered to be performed as an alternative.