Re: Sivaraman A, Ramasamy V, Aarthy P, Sankar V, Sivaraman PB. Safety and feasibility of freehand transperineal prostate biopsy under local anesthesia: Our initial experience. Indian J Urol 2022;38:34-41.

We read with great interest the newly published study on freehand transperineal prostate biopsy, published in the journal.[1] I congratulate the researchers for making an important contribution to the literature and clinical practice on cognitive fusion biopsy. In the present study, the authors shared the results of freehand transperineal cognitive fusion biopsy using the PrecisionPoint device (PrecisionPoint™ BXTAccelyon) in 50 patients and reported that this technique has satisfactory cancer (overall; 82% and clinical significant prostate cancer [CSPC]; 78%) rates and acceptable complications.

Three types of targeted biopsy techniques based on multiparametric-magnetic resonance imaging (Mp-MRI) have been developed so far; mp-MRI/TRUS fusion biopsy, direct MRI-guided (in-bore) biopsy, and cognitive fusion biopsy.

In a recent meta-analysis comparing the three targeted biopsy techniques, it was reported that all three techniques had similar CSPC detection rates.[2] Similarly, in the current (2022) guideline of the European Association of Urology, it is stated that in cases where a suspicious lesion is observed on mp-MRI, either mp-MRI/TRUS fusion biopsy, in-bore biopsy, or cognitive fusion biopsy can be used.[3] Of these three techniques, mp-MRI/TRUS fusion biopsy and in-bore biopsy have a major cost problem as they require additional software. However, there is no serious cost problem with cognitive fusion biopsy. Despite all this, cognitive fusion biopsy has been much less accepted by physicians and patients and has found less place in the literature and clinical practice. At this point, the influence of the industry is a fact that cannot be ignored.

Although it remains in the background in the literature, there have been some important developments in cognitive fusion biopsy. Using smart glasses and various simple coordinate-based methods, it has been shown that this method can have better results.[456] In addition, it was reported that cognitive fusion biopsy, which was previously performed entirely through the transrectal route, can also be performed by the transperineal route, which has a significant advantage in terms of local anesthesia requirement and infective complications, especially urosepsis.[7] However, a freehand transperineal cognitive fusion biopsy technique was defined with a simple instrument (PrecisionPoint device) without the need for a template unit.[8]

As authors, we attach great importance to this technique (freehand transperineal cognitive fusion prostate biopsy) reported by researchers in terms of both not being under the influence of the entire industry and lowering infective complications. I would like to emphasize that freehand transperineal cognitive fusion biopsy should become widespread in our clinical practice and that our experience in this field should increase, especially for clinics that do not have mp-MRI/TRUS fusion biopsy and in-bore biopsy devices due to cost. Otherwise, our prostate fusion biopsy practices will not be shaped in the light of scientific facts but will be shaped entirely by the influence of the industry.