A Triple Clinical Filter Model for Selective Omission of Systematic Cores in Transperineal Cognitive Prostate Biopsy: A Retrospective Observational Study

ABSTRACT Background To determine whether systematic biopsy can be safely omitted in selected patients undergoing antibiotic‐free transperineal cognitive MRI‐targeted prostate biopsy under local anesthesia, and to identify clinical and imaging parameters associated with cognitive biopsy superiority. Methods This retrospective study included patients who underwent antibiotic‐free transperineal prostate biopsy under local anesthesia. All patients had multiparametric prostate MRI (mpMRI) visible lesions and received both systematic and cognitive MRI‐targeted biopsy. Targeted cores were obtained from all PI‐RADS 4–5 lesions and from PI‐RADS 3 lesions only when PSA density was ≥ 0.10 ng/mL/cm 3 . Cognitive biopsy non‐inferiority was defined as an ISUP Grade Group equal to or higher than that obtained from systematic cores in the same patients. PSA density, MRI lesion size, and PI‐RADS category were incorporated into a multivariable model to predict when systematic sampling would not add diagnostic value. Results The multivariable model incorporating PSA density, MRI lesion size, and PI‐RADS category demonstrated good discriminatory performance (AUC 0.881, sensitivity 92.6%, specificity 84.8%). In patients meeting all predefined model criteria, cognitive biopsy achieved concordant or superior grading in 95.2% of cases, whereas in those not meeting these criteria, systematic biopsy provided higher‐grade detection in all cases within this subgroup. Conclusions In carefully selected patients with elevated PSA density, larger mpMRI visible lesions, and high PI‐RADS scores, transperineal cognitive MRI‐targeted biopsy may support the selective omission of systematic cores without compromising diagnostic reliability. In contrast, systematic sampling remains indispensable in lower‐risk profiles, underscoring the value of a risk‐adapted biopsy strategy.