title: Contemporary role of systematic prostate biopsies: indications, techniques, and implications for patient care.
abstract: BACKGROUND
  Prostate cancer (PCa) screening to detect early stage PCa has resulted in increased identification of small-volume, low-grade PCa, many of which meet criteria for clinically indolent disease. Nevertheless, there remains some degree of underdetection of high-risk PCa in substantial numbers of men despite current diagnostic strategies.
  
  
  OBJECTIVE
  To discuss the contemporary role of prostate biopsy (PB), focusing on the indications, techniques, and limitations of current PB techniques and evolving techniques affecting patient care.
  
  
  METHODS
  A comprehensive Medline search was performed using the medical subject heading search terms prostate cancer, detection, prostate biopsy, significant cancer, and diagnosis, with restriction to the English language. Emphasis was given to publications within the past 5 yr.
  
  
  RESULTS
  Because abnormal digital rectal examination (DRE) and prostate-specific antigen (PSA) tests alone lack specificity for cancer, there is no universal indication for PB. This lack has inspired exploration for a cancer-specific biomarker and prediction tools such as risk calculators. Indication for biopsy should involve a balance between the underdiagnosis of high-risk cancers and the potential risks for the overdetection of clinically insignificant cancers as well as biopsy-related morbidity. Evidence supports the inclusion of laterally directed cores during transrectal ultrasound (TRUS) PB in addition to the traditional sextant pattern, which significantly improves cancer detection without a demonstrable increase in morbidity. These data indicate that such PB templates, typically 12 cores, represent the optimal template in initial PB. Optimised techniques and templates for repeat PB remain controversial. However, debate continues regarding indications, sampling number, and location as well as on the potential of modern image-guided approaches or three-dimensional (3D) mapping biopsy in this unique setting. Additional limitations of repeat PB techniques include associated procedural risks if general anaesthesia is required and inherent sampling errors of template-based techniques that are not targeted to the specific tumour site.
  
  
  CONCLUSIONS
  Current data support the utility of extended PB templates for initial TRUS PB intended to detect clinically significant PCa. Repeat PB in the setting of prior negative PB on the grounds of clinical suspicion or for risk-stratified approaches to management of low risk PCa requires balancing overdetection of low-risk cancer with the potential to miss significant cancer. Several options, including modern image-guided targeting, biomarker development, transrectal saturation PB, and 3D template mapping PB, are changing the clinical paradigms for evaluation and management. Evidence to support adopting approaches other than the current established standards should be tested through appropriately designed prospective studies.
authors.affiliation: Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. ukimura@usc.edu
authors.forename: Osamu
authors.initials: O
authors.lastname: Ukimura
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Coleman
authors.forename: Alex
authors.initials: A
authors.lastname: de la Taille
authors.forename: Mark
authors.initials: M
authors.lastname: Emberton
authors.forename: Jonathan I
authors.initials: JI
authors.lastname: Epstein
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Freedland
authors.forename: Gianluca
authors.initials: G
authors.lastname: Giannarini
authors.forename: Adam S
authors.initials: AS
authors.lastname: Kibel
authors.forename: Rodolfo
authors.initials: R
authors.lastname: Montironi
authors.forename: Guillaume
authors.initials: G
authors.lastname: Ploussard
authors.forename: Monique J
authors.initials: MJ
authors.lastname: Roobol
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Scattoni
authors.forename: J Stephen
authors.initials: JS
authors.lastname: Jones
mesh_terms: D062005:Biopsy, Large-Core Needle / Q000379:methods / Q000706:statistics & numerical data; D051517:Digital Rectal Examination / Q000706:statistics & numerical data; D055088:Early Detection of Cancer / Q000379:methods / Q000706:statistics & numerical data; D006801:Humans; D061705:Image-Guided Biopsy / Q000379:methods / Q000706:statistics & numerical data; D007610:Kallikreins / Q000097:blood; D008297:Male; D018579:Patient Selection; D011467:Prostate / Q000000981:diagnostic imaging / Q000473:pathology*; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000473:pathology*; D012680:Sensitivity and Specificity; D014463:Ultrasonography
chemical_list: C549870:KLK3 protein, human; D007610:Kallikreins; D017430:Prostate-Specific Antigen