Transrectal ultrasound guided biopsy of the prostate: random sextant versus biopsies of sono-morphologically suspicious lesions

Transrectal ultrasound (TRUS) guided multiple systematic random biopsies are presently the method of choice for determining the presence or absence of prostate cancer. TRUS image information is only used to guide the biopsy needle into the prostate, but not to localize and target cancerous lesions. Our aim in this study was to evaluated the possible predictive value of tumor suspicious endosonographic lesions of the prostate for prostate biopsies. We prospectively compared six systematic biopsies with lesion guided biopsies in a consecutive series of 217 patients. All patients had a prostate specific antigen (PSA) level of >4 ng/ml without a history of prostate disease. In a subgroup of 145 men with sonomorphologic lesions suggestive for prostate cancer (hypoechoic areas or asymmetries predominantly in the peripheral zone), lesion-guided biopsies were taken in addition to the systematic biopsies. We evaluated the number of tumors which were diagnosed or missed by both of the biopsy strategies. Of the 217 evaluated patients, 64 (29%) had histology confirmed cancer. Four patients with negative sextant biopsies had a positive TRUS guided biopsy. Out of 145 patients with a normal TRUS, three were cancer positive by sextant biopsy. A total of 1,387 individual biopsy cores were evaluated. Of the 1,304 systematic biopsy cores, 182 (14%) were positive and 1,122 (86%) negative. Of the 329 TRUS lesion guided biopsy cores 139 (42%) were positive and 190 (58%) negative. Patients with tumor suggestive TRUS lesions have a considerably higher risk of being diagnosed with prostate cancer compared to patients without such lesions. Both systematic sextant and TRUS lesion guided biopsies missed detectable prostate cancer in a minority of patients. Taking the endosonographic morphology of the prostate gland into consideration for biopsy strategies may improve the quality of the biopsy and avoid unnecessary invasive procedures in selected cases.     

One 10-core prostate biopsy is superior to two sets of sextant prostate biopsies

OBJECTIVES: To compare the efficiency of different transrectal ultrasonography (TRUS)-guided prostate biopsy techniques for detecting prostate cancer. MATERIALS AND METHODS: In all, 81 prostates from radical prostatectomy were used and two consecutive sets of sextant biopsies and one 10-core biopsy taken in each specimen. The 10-core biopsy consisted of a sextant biopsy and four cores from the far lateral areas of the prostate. To simulate a transrectal biopsy procedure, all biopsies were taken under TRUS guidance. RESULTS: In the first set of sextant biopsies 44 prostate cancers (54%) were detected and in the second set 51 (63%). Combining both sets of sextant biopsies 57 (70%) of the carcinomas were detected. One set of 10-core biopsies detected 66 (82%) of all prostate cancers. Overall, with the 10-core biopsies 16% more prostate tumours were diagnosed than with two consecutive sets of sextant biopsies. To find the same number of prostate cancers as with the 10-core technique, 14% of patients undergoing sextant biopsy would require a second set and 11% at least a third set of biopsies. CONCLUSIONS: The 10-core prostate biopsy technique is superior to the commonly used sextant technique and could spare patients unnecessary repeated biopsy. Even after including a second set of sextant biopsies, the total detection rate with these 12 biopsies was inferior to the 10-core technique.     

An extended 10-core transrectal ultrasonography guided prostate biopsy protocol improves the detection of prostate cancer

OBJECTIVE: To evaluate the efficacy of TRUS guided 10-core biopsy strategy for Turkish patients who had biopsy of the prostate for the first time. METHODS: Between February 2001 and May 2003, 303 consecutive men with suspected prostate cancer were included in the study. Indications for TRUS guided prostate biopsy were: abnormal digital rectal examination and/or a serum PSA over 2.5 ng/ml. All of the patients underwent a 10-core biopsy protocol with additional core from the each suspicious area detected by TRUS. Besides the sextant technique, 4 more biopsies were obtained from the lateral peripheral zone. We aimed to analyze whether cancer detection improved with the extended versus the standard sextant biopsy in our series overall and in each subgroup. RESULTS: Of 303 patients 94 (31%) were positive for prostate cancer. Median age and PSA of prostate cancer patients were significantly higher than of the non-cancer patients. Besides prostate volumes of the cancer patients were significantly lower than of the non-cancer ones. The cancer detection rates were 31% (94/303) and 23.1% (70/303) for the 10-core biopsy strategy and sextant biopsy strategies, respectively. Thus the 10-core biopsy technique increased cancer detection rate by 25.5% (24/94) for the whole group of patients. A statistically significant number of additional cancers were detected with 10-core biopsy strategy for all the subgroups of the patients. Furthermore 10-core biopsy protocol detected more cancers (at least 6.4%) than all the probable different combinations of 8-core biopsy protocols. Among the 94 cancer patients, biopsy from a suspicious area revealed cancer in 31.9% of them; however, in all of these patients cancer was already present in the 10-core biopsy. On the other hand, lesion biopsies revealed 5.7% additional cancers if sextant technique was used. There were only 3 (0.9%) serious complications requiring hospitalization and all 3 were infections controlled by appropriate antibiotics. CONCLUSION: Adding 4 lateral peripheral biopsies to the conventional sextant biopsy (10-core biopsy strategy) technique has increased the cancer detection rate by 25.5% without significant morbidity and without increasing the number of insignificant cancers. 10-core biopsy protocol was superior to all probable 8-core biopsy protocols in our study group. Additional biopsies from suspicious areas detected by transrectal ultrasonography revealed no further benefit if 10-core technique was used. We therefore suggest that 10-core biopsy protocol should be the preferred strategy in early detection of prostate cancer.     

Prostatic Transrectal Ultrasound (TRUS) Guided Biopsy Schemes and TRUS Prostatic Lesion-Guided Biopsies

Objectives: Recent data support the sextant TRUS guided biopsy scheme of the prostate and TRUS prostatic lesion-guided biopsies are inadequate to detect all clinically important cancers. Consequently, different types of schemes with more than six biopsies have recently been proposed. The type of scheme and the number of biopsies needed to optimize the detection rate of prostate cancer is still a somewhat controversial issue. In order to draw attention to the most interesting issues and controversies involving needle biopsies, we describe not only the most common methods used but also some of the new schemes proposed in literature.Methods: Literature on prostate biopsy was reviewed and a selection of articles made. Keywords used for the Medline search included: prostate cancer, biopsy, transrectal ultrasound and diagnosis.Results: Over the last few years, an increasing number of investigators have modified the standard sextant biopsy scheme, increasing the number and areas of the prostate sampled, especially biopsies taken more laterally or in the anterior horn or medially towards the apex of the prostate. Cancer yield does not appear to be related solely to the number of biopsies but also to the regions of the prostate sampled.Conclusions: In the current PSA era, prostatic biopsies only performed at lesions detected by TRUS are obsolete. Sextant and lesion-directed biopsies maximizes detection rate using the lowest possible number of biopsy cores if hypoechoic lesions are clearly visible. In the case of a negative TRUS and/or digital rectal examination, the ideal number of cores and prostate areas requiring sampling is still not defined, but the use of 10 or 12 multiple biopsies is becoming routine in many centers. In the future, biopsy techniques will probably be individualized for each patient according to TRUS findings, prostatic volume and PSA levels.     

Is extended and saturation biopsy necessary?

Prostate biopsy (PBx) techniques have significantly changed since the original Hodge's ‘sextant scheme’, which should now be considered obsolete. The feasibility of carrying out a biopsy scheme with a high number of cores in an outpatient setting is a result of the great improvement and efficacy of local anesthesia. Peri‐prostatic nerve block with lidocaine injection should be considered the ‘gold standard’ because it provides the best pain relief to patients undergoing PBx. The optimal extended protocol should now include the sextant template with an additional 4–6 cores directed laterally (anterior horn) to the base and medially to the apex. Saturation biopsies (i.e. template with ≥20 cores, including transition zone) should be carried out only when biopsies are repeated in patients where there is a high suspicion of prostate cancer. Complementary imaging methods (such as color‐ and power‐Doppler imaging, with or without contrast enhancement, and elastography) could be used in order to increase the accuracy of biopsy and reduce the number of unnecessary procedures. Nevertheless, the routine use of these methods is still under evaluation.     

Optimal combinations of systematic sextant and laterally directed biopsies for the detection of prostate cancer

PURPOSE: The standard sextant protocol for obtaining transrectal ultrasound guided biopsy of the prostate has been shown to underestimate the presence of prostate cancer. Studies have demonstrated an increased cancer detection rate with additional laterally directed biopsies. We compared the sensitivity of individual biopsy cores and evaluated combinations of these cores to identify an optimal biopsy strategy. MATERIALS AND METHODS: A total of 396 consecutive patients underwent biopsy of the lateral peripheral zone in addition to standard sextant biopsy. The cancer detection rate for each biopsy core was calculated. The sensitivity of different combinations of biopsy cores was compared with those of standard sextant biopsies and with a 12 core biopsy protocol that combined the standard sextant biopsy with a complete set of laterally directed cores. RESULTS: Cancer was detected in 160 of 396 (40.3%) patients. Of the possible combinations of biopsy cores a strategy that included laterally directed cores at the base, mid gland and apex of the prostate with mid lobar base and apical cores detected 98.5% of cancers. The detection rate of this 10 core biopsy regimen was significantly better than that of the standard sextant protocol (p < or =0.001), and was equivalent to that of the 12 core regional biopsy (p > or =0.302). CONCLUSIONS: The standard sextant protocol failed to detect a large proportion of cancers located laterally in the peripheral zone. A 10 core biopsy regimen that combined laterally directed cores at the base, mid gland and apex of the prostate with mid lobar biopsy cores at the base and apex maximizes the sensitivity of transrectal ultrasound guided systematic biopsy.     

Impact of additional sampling in the TRUS-guided biopsy for the diagnosis of prostate cancer

AIM: To evaluate the diagnostic value of 10+ systematic sampling technique when performing transrectal ultrasound-guided (TRUS) prostate biopsy, compared with the sextant biopsy technique for patients with suspected prostate cancer. METHODS: 286 patients with suspected prostate cancer were included in the study. Patients were eligible for the study if they had serum levels of prostate-specific antigen (PSA) >4 ng/ml or ratio PSA <0.25 and/or an abnormal digital rectal examination (DRE). The population sample was divided in three groups: (1) those with positive PSA, PSA ratio and DRE (70 patients); (2) those with positive PSA and PSA ratio but normal DRE (178 patients), and (3) those with positive PSA and PSA ratio, positive PSA velocity and a negative biopsy in the previous 6-month period (38 patients). In addition to the conventional sextant prostate biopsy cores, four more biopsies were obtained from the lateral peripheral zone (10 core biopsy protocol). Additional cores (total of 12-14) were also randomly selected in case of larger prostates (>60 ml) or from suspicious foci revealed by transrectal ultrasound. All additional biopsy cores were submitted separately to the pathological department. RESULTS: Cancer was detected in 55.7% (39/70) and 69% (48/70) of the patients (for sextant core and for the extended biopsy protocols, respectively) in the first study group, 11% (20/178) and 23% (41/178) of the patients (for the sextant and the extended biopsy protocols, respectively) in the second study group, and 42% (16/38) and 63% (24/38) of the patients (for the sextant and the extended biopsy protocols, respectively) in the third study group. The addition of the lateral peripheral zone (PZ) of the prostate to the sextant biopsy showed a 23, 105 and 50% increase in the number of cancers diagnosed in the first, second and third study groups, respectively. The improvement of cancer detection rate (sensitivity) was statistically significant for all groups evaluated. CONCLUSION: The 10+ systematic TRUS-guided prostate biopsy improves the detection rate of prostate cancer compared to the sextant biopsy technique alone, especially when performed in men with positive PSA, PSA ratio, and negative DRE.     

The Effect of Prior Biopsy Scheme on Prostate Cancer Detection for Repeat Biopsy Population: Results of the 14-core Prostate Biopsy Technique

OBJECTIVES: To evaluate the diagnostic performance of 14-core repeat biopsy protocol and the impact of prior biopsy scheme on repeat prostate biopsy group. METHODS: 211 patients had repeat biopsy using 14-core protocol consisting of 10-core peripheral zone (classical sextant+4 lateral peripheral cores) and 4-core transitional zone (TZ) biopsies. The diagnostic yield was determined both in patients who had previously undergone sextant or 10-core biopsy protocol. RESULTS: Overall cancer detection rate was 25.6%. 14-core biopsy technique detected cancer in 36.1 and 18.7% of the patients who had a previous sextant biopsy and 10-core biopsy protocol, respectively (P = 0.005). Patients with and without high-grade prostatic intraepithelial neoplasia (HGPIN) in the previous sextant biopsy had 56.5 and 28.3% cancer detection rates on the subsequent extended biopsy, respectively (P = 0.017) Patients who had previous 10-core biopsy with and without HGPIN revealed 22.9 and 17.2% cancer detection rates, respectively (P = 0.465) Additional four lateral peripheral cores detected 33% (3/30) and 17% (4/24) of cancers in patients with previous sextant and 10-core biopsy, respectively. 3.7% of the patients had tumor only in the TZ and none of them had prior extended biopsy. CONCLUSIONS: The yield of extended 14-core repeat biopsy protocol was higher in patients with previous negative sextant biopsy compared to the patients with previous negative 10-core biopsy. HGPIN history found on previous sextant biopsy was a strong cancer predictor on repeat biopsy; same was not true for the patients with previous 10-core biopsy. The yield of lateral peripheral cores and TZ biopsies were lower in patients with prior negative extended biopsy.     

Increasing prostate biopsy cores based on volume vs the sextant biopsy: a prospective randomized controlled clinical study on cancer detection rates and morbidity

OBJECTIVE: To determine if a volume-adjusted increase in the number of biopsy cores could detect more prostate cancers than the standard sextant biopsy alone, without increasing morbidity, and to determine its applicability in Malaysian patients, as a standard sextant biopsy misses 20-25% of prostate malignancies. PATIENTS AND METHODS: In a prospective randomized study of patients undergoing transrectal ultrasonography (TRUS)-guided biopsy for a prostate-specific antigen (PSA) level of 4-20 ng/mL without abnormal digital rectal examination (DRE), the men were divided into five main groups (A-E) with prostate volumes of <20, 20-40, 40-60, 60-80 and >80 mL, respectively. Patients in groups B-E were randomized into sextant (B1 to E1) and increased biopsy-core subgroups, i.e. B2 (eight cores), C2 (10 cores), D2 (12 cores) and E2 (14 cores). The morbidity profile was also evaluated during and after TRUS biopsy, assessing a pain score, rectal bleeding, haematuria, haemospermia and development of fever. In all, 132 patients were recruited (mean age 67.8 years; mean PSA 9.41 ng/mL). RESULTS: The overall cancer detection rate was 24% (32 men). Taking more cores detected 65.5% of cancers, and the sextant biopsy 34.5% (P = 0.0025), but did not increase the overall morbidity. CONCLUSIONS: The volume-adjusted, increased-core regimen significantly increased the positive biopsy rate of TRUS-guided prostate biopsies with no added morbidity.     

Prostate cancer detection with office based saturation biopsy in a repeat biopsy population

PURPOSE: Patients at increased risk for prostate cancer with previously negative biopsies pose a diagnostic challenge. We have previously demonstrated that extensive saturation biopsy can be performed in an office setting. We now report the diagnostic yield of office saturation biopsy in patients at increased risk for prostate cancer and at least 1 negative prior biopsy. MATERIALS AND METHODS: We performed saturation prostate biopsy with local anesthesia in the office in 116 patients with at least 1 prior negative biopsy and with certain risk factors, namely persistently elevated prostate specific antigen, abnormal digital rectal examination, or prior atypia or PIN on prior biopsy. RESULTS: A total of 34 cancers were detected for an overall diagnostic yield of 29%. A 64% detection rate was noted when a patient had undergone a single prior sextant biopsy. Subgroup analysis revealed a cancer detection rate of 41% when only prior sextant biopsies were performed, and a 24% detection rate when 10 or more cores were taken on prior biopsy. The detection rate was 33% when only 1 prior biopsy was taken and it was 24% when 2 or more prior biopsies were performed. CONCLUSIONS: Saturation biopsy can be performed safely and effectively in the office with a significant diagnostic yield even in patients with previous extended biopsy schemes. We believe that it should be the next diagnostic step after an initial negative biopsy in patients in whom the diagnosis of prostate cancer is strongly suspected.     

Update on prostate biopsy technique

PURPOSE OF REVIEW: Over the past decade, a considerable number of modifications have been made to the techniques for prostate cancer biopsy. In this review, we discuss the developments reported in the literature since January 2003. RECENT FINDINGS: The addition of laterally directed biopsies has enhanced the diagnostic performance of the conventional sextant biopsy approach. Several models of the extended biopsy technique have been introduced that increase the number of cores by combining sextant and lateral biopsies to enhance the cancer detection rate. Several reports have shown that the cancer detection rate decreases as prostate volume increases, compared with an increasing cancer detection rate on repeat biopsy in men with large prostate gland volumes. Other studies have shown that the percentage of positive cores and the total percentage of tumor found at biopsy are significant independent predictors of pathological outcome on multivariate analysis. In randomized, double-blind studies, infiltration of the neurovascular bundles with lidocaine significantly reduces pain associated with extended biopsies. SUMMARY: Current reports have suggested that: (1) extended biopsy schemes decrease the false-negative rate compared with conventional sextant biopsy; (2) laterally directed biopsies from the anterior horn should be included in extended biopsy protocols; and (3) local anesthesia reduces pain associated with extended biopsy.     

不同前列腺穿刺活检方案检出前列腺癌的比较

目的探讨理想的前列腺穿刺活检方案。方法临床表现怀疑前列腺癌患者214例，其中前列腺特异抗原〉4．0ng／ml 203例。均行13针前列腺穿刺活检术。年龄50～90岁，平均70岁；PSA水平0．8～112．3ng／ml，平均18．7ng／ml；前列腺体积12．3～182．5ml，平均61．3ml；直肠指诊阴性173例，阳性者41例。依穿刺结果，对比分析13针中6、8、10和13针穿刺阳性率。结果13针穿刺阳性率为36．0％（77／214）。在各种穿刺点组合中包含前列腺尖部、中部、底部、外侧中部、外侧底部的10针法能发现全部前列腺癌阳性病例的97．4％，与13针穿刺结果的差异无统计学意义（P=0．5）。结论对于初次前列腺活检的病例，包含尖部、中部、底部、外侧中部、外侧底部的10针法是较为合理的选择。     

Ultrasound-guided transrectal extended prostate biopsy： a prospective study

AIM: To evaluate the diagnostic value of the 10 systematic transrectal ultrasound-guided (TRUS) prostate biopsy compared with the sextant biopsy technique for patients with suspected prostate cancer. Methods: One hundred and fifty-two patients with suspected prostate cancer were included in the study. Patients were entered in the study because they presented with high levels of prostate specific antigen (PSA) (over 4 ng/mL) and/or had undergone an abnormal digital rectal examination (DRE). In addition to sextant prostate biopsy cores, four more biopsies were obtained from the lateral peripheral zone with additional cores from each suspicious area revealed by transrectal ultrasound. Sextant, lateral peripheral zone and suspicious area biopsy cores were submitted separately to the pathological department. Results: Cancer detection rates were 27.6% (42/152) and 19.7% (30/152) for the 10-core and sextant core biopsy protocols, respectively. Adding the lateral peripheral zone (PZ) to the sextant prostate biopsy showed a 28.6% (12/42) increase in the cancer detection rate in patients with positive prostate cancer (P < 0.01). The cancer detection rate in patients who presented with elevated PSA was 29.3% (34/116). When serum PSA was 4-10 ng/mL TRUS-guided biopsy detected cancer in 20.6%, while the detection rate was 32.4% and 47.0% when serum PSA was 10-20 ng/mL and above 20 ng/mL, respectively. Conclusion: The 10 systematic TRUS-guided prostate biopsy improves the detection rate of prostate cancer by 28.6% when compared with the sextant biopsy technique alone, without increase in the morbidity. We therefore recommend the 10-core biopsy protocol to be the preferred method for early detection of prostate cancer.     

Optimizing performance and interpretation of prostate biopsy: a critical analysis of the literature

Context

The number and location of biopsy cores and the interpretation of prostate biopsy in different clinical settings remain the subjects of continuing debate.

Objective

Our aim was to review the current evidence regarding the performance and interpretation of initial, repeat, and saturation prostatic biopsy.

Evidence acquisition

A comprehensive Medline search was performed using the Medical Subject Heading search terms prostate biopsy, prostate cancer, detection, transrectal ultrasound (TRUS), nomogram, and diagnosis. Results were restricted to the English language, with preference given to those published within the last 3 yr.

Evidence synthesis

At initial biopsy, a minimum of 10 but not >18 systematic cores are recommended, with 14–18 cores in glands ≥50 cm³. Biopsies should be directed laterally, and transition zone (TZ) cores are not recommended in the initial biopsy setting. Further biopsy sets, either as an extended repeat or as a saturation biopsy (≥20 cores) including the TZ, are warranted in young and fit men with a persistent suspicion of prostate cancer. An immediate repeat biopsy is not indicated for prior high-grade prostatic intraepithelial neoplasia diagnosis given an adequate extended initial biopsy. Conversely, biopsies with atypical glands that are suspicious but not diagnostic of cancer should be repeated within 3–6 mo. Overall recommendations for further biopsy sets (a third set or more) cannot be made. Transrectal ultrasound–guided systematic biopsies represent the standard-of-care method of prostate sampling. However, transperineal biopsies are an up-to-standard alternative.

Conclusions

The optimal prostatic biopsy regimen should be based on the individualized clinical setting of the patient and should follow the minimum standard requirements reported in this paper.     

Individualization of the biopsy protocol according to the prostate gland volume for prostate cancer detection

PURPOSE: In this study we assessed the relative yield of 10 core biopsy, and the whole range of alternative 8 and 6 core biopsy protocols over that of the classic sextant biopsy protocol. We determined the optimum number of cores per biopsy according to prostate volume in patients who experienced prostate biopsy for the first time. MATERIALS AND METHODS: A total of 503 men with the indications of abnormal digital rectal examination and/or serum prostate specific antigen greater than 2.5 ng/ml were included in the study. All patients underwent a 10 core biopsy protocol with an additional 1 core from each suspicious area detected by transrectal ultrasound. Prostate volume was divided into quartiles, namely 14.9 to 35, 35.1 to 50, 50.1 to 65 and 65.1 to 150 cc. The optimum number of biopsy cores was determined in patients with different prostate volumes. RESULTS: Median age was 63 years and prostate specific antigen was 7.4 ng/ml in the whole group. Of 503 patients 159 (31.6%) were positive for prostate cancer. Cancer detection rates decreased significantly from 49.6% to 20.8% as prostate volume increased in preset quartiles. Lesion biopsies revealed the lowest unique cancer detection rates for all prostate volume quartiles (0% to 3%). There was an obvious positive trend in cancer detection rates in favor of the 10 core biopsy protocol over sextant biopsies in all patient groups. Classic sextant biopsy protocol proved to be inadequate for all prostate volumes. Among sextant biopsy protocols laterally placed cores including the apex, lateral mid gland and lateral base had the best cancer detection rates (81% to 95%). The 8 core biopsy scheme consisting of the apex, mid gland, lateral mid gland and lateral base resulted in an only 1% lower detection rate (97%) than the 10 core biopsy protocol in the lowest quartile. The yield of the 10 core biopsy protocol in patients with a prostate volume of between 35.1 and 150 cc outscored that of the optimal 8 core biopsy scheme including the apex, base, lateral mid gland and lateral base with 3% to 8% differences in the cancer detection rate. CONCLUSIONS: The 10 core biopsy protocol must be used in all group of patients except patients with a prostate volume of 14.9 to 35 cc. In patients with a prostate volume of 14.9 to 35 cc the 8 core biopsy protocol consisting of the apex, mid gland, lateral mid gland and lateral base can be used since it revealed results similar to those of the 10 core biopsy protocol. The classic sextant biopsy protocol seemed inadequate for all prostate volumes. Patients with a larger prostate had lower cancer detection rates. Transrectal ultrasound directed lesion biopsies may be omitted when using 10 core biopsy protocols since the yield of these biopsies was less than 2%.     

Individualized prostate biopsy strategy for Chinese patients with different prostate-specific antigen levels

Aim： To evaluate the best individualized prostate biopsy strategies for Chinese patients with suspected prostate cancer. Methods： The present study included 221 Chinese patients who underwent transrectal ultrasound guided prostate biopsies for the first time. All patients underwent the same 10-core biopsy protocol. In addition to the Hodge sextant technique, four more biopsies were obtained from the base and middle regions of bilateral peripheral zones. The differences between 10-core and sextant strategies in cancer detection among patients with different prostate specific anitgen （PSA） levels were evaluated. The relationship between PSA level, number of positive biopsy cores and organ-confined cancer rate in prostate cancer patients was also analyzed. Results： The overall prostate cancer detection rate was 40.7% in the 221 patients. The 10-core strategy increased cancer detection by 6.67% （6/90） in our patients （P 〈 0.05）. The increased cancer detection rates decreased significantly when the patient PSA level increased from 0-20 ng/mL to 20.1-50 ng/mL and 〉 50 ng/mL （P 〈 0.01）. The number of positive biopsy cores in prostate cancer patients increased significantly with increasing patient PSA level （P 〈 0.01）. The rate of organ-confined prostate cancer decreased significantly with increasing patient PSA level （P 〈 0.01）. Conclusion： The extended 10- core strategy is recommended for Chinese patients with PSA 〈 20 ng/mL and the sextant strategy is recommended for those with PSA〉 50 ng/mL. For patients with PSA ranging from 20.1 ng/mL to 50 ng/mL, the 10-core strategy should be applied in patients with life expectancy 〉 10 years and the sextant strategy should be applied in those with life expectancy 〈 10 years. （Asian J Androl 2008 Mar; 10： 325-331）     

Prostate biopsy strategies. A review of the literature

IntroductionIn 1987 transrectal ultrasound was described like the technique for guiding prostate biopsy. Since that time different options of transrectal ultrasound guided prostate biopsy were described.Material and MethodsWe did a reviewed of the different techniques and cores distribution in the prostate biopsy, also we describes the patient preparation and the most important complications.ResultsThe majority of the reviewed showed an increase in the sensibility rates with the extended transrectal ultrasound guided prostate biopsies. These improvements generally are due to the most lateral zones.ConclusionUntil now, due to a great experience and a low complications rate, the transrectal ultrasound guided prostate biopsy strategy should be extended respect the classical sextant biopsy with cores from the most lateral zones of the prostate.     

Trans-rectal ultrasound guided biopsy of the prostate: Nationwide diversity in practice and training in the United Kingdom

Introduction: TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. However the practice is highly variable across the United Kingdom. We survey the standard approaches to TRUS biopsy of prostate, highlighting the nationwide diversity of practice and training. Methods: One hundred and eighty questionnaires were sent out to specialist registrars, investigating the number of prostate biopsy cores taken, the use of prophylactic antibiotics, rectal preparation and local analgesia in TRUS biopsy of the prostate. One hundred and fourteen trainees (63%) returned the questionnaires. Twenty-three percent reported sextant biopsy as standard, 36% taking eight-core and 26% taking 10 or more cores. There is no standard regime for antibiotic prophylaxis. Eighteen percent also reported rectal preparation as routine. Thirty-eight percent of the patients receive local anaesthesia prior to the biopsy. Overall, 42% of the TRUS biopsies are carried out by urologists, 29% by radiologists and 21% by both. Six percents have nurse practitioners’ involvement. Fifty-six percent of trainees are involve in the TRUS biopsy, 68% do not think they received enough training to carry out the procedure. Conclusions: TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. Our survey highlights nationwide diversity in practice in the UK with respect of the number of cores taken, antibiotic prophylaxis and local anaesthesia utilisation. This raised the issue of standardising the practice. More urologists are also actively taking part in this procedure, making the structured training increasingly important.     

Effect of peripheral biopsies in maximising early prostate cancer detection in 8-, 10- or 12-core biopsy regimens

OBJECTIVE: To assess the cancer detection rate per individual core biopsy in a 12-core protocol and develop an optimal biopsy regimen for detecting early prostate cancer. PATIENTS AND METHODS: The study included 445 new patients who had a 12-core transrectal ultrasonography (TRUS)-guided prostatic biopsy over a 40-month period. The 12- core biopsy protocol included parasagittal sextant and six peripheral biopsies. The cancer detection rate per individual core was evaluated to give an optimal biopsy protocol. RESULTS: Prostate cancer was detected in 142 patients (31.9%). Parasagittal sextant biopsy would have failed to detect 40 (28.2%) of the cancers. Among the various possible biopsy protocols, the optimum 10-core biopsy strategy excluding the parasagittal mid-zone biopsies from the 12-core protocol achieved a cancer detection rate of 98.6%. CONCLUSION: The cancer detection rate increased from 71.8% for parasagittal sextant biopsies to 88.7% by adding peripheral basal biopsies (8-biopsy protocol); 98.6% of cancers in the series would have been detected with a 10-biopsy strategy omitting the parasagittal mid-zone biopsies. Thus we recommend a 10-core protocol incorporating six peripheral biopsies in patients with elevated age- specific prostate-specific antigen levels (2.6-10.0 ng/mL) for maximising cancer detection.     

Repeat prostate biopsy: who,how and when?. a review

Urologists are frequently faced with the dilemma of treating a patient with a high index of suspicion of prostate cancer (PCa), but an initial set of negative biopsies. In this review, we evaluated the current knowledge on repeat prostate biopsies, focusing on when to perform them and in which patients, how many samples to take, where to direct the biopsies and what morbidity should be expected. We focussed on the available literature and the multicenter European Prostate Cancer Detection (EPCD) study. The EPCD study included 1051 men with a total PSA from 4 to 10 ng/ml who underwent a transrectal ultrasound (TRUS) guided sextant biopsy and a repeat biopsy in case of a negative initial biopsy. Most studies support that increasing the number of biopsy cores as compared to the sextant technique and improving prostate peripheral zone (PZ) sampling result in a significant improvement in the detection of prostate cancer without increase in morbidity or effects on quality of life. Re-biopsy can be performed 6 weeks later with no significant difference in pain or morbidity. At least 10% of patients with negative sextant prostatic biopsy results in the EPCD study were diagnosed with PCa on repeat biopsy, percent free PSA and PSA density of the transition zone being the most accurate predictors. Despite differences in location (more apico-dorsal) and multifocality, pathological and biochemical features of cancers detected on initial and repeat biopsy were similar, suggesting similar biological behavior and thus advocating for a repeat prostate biopsy in case of a negative finding on initial biopsy. Indications and ideal number of biopsy cores to take when repeating biopsies in patients who already underwent extensive biopsy protocols on the first biopsy remains to be determined.