title: Systematic ultrasound-guided saturation and template biopsy of the prostate: indications and advantages of extended sampling.
abstract: OBJECTIVE
  Prostate biopsy (PB) is the gold standard for the diagnosis of prostate cancer (PCa). However, the optimal number of biopsy cores remains debatable. We sought to compare contemporary standard (10-12 cores) vs. saturation (=18 cores) schemes on initial as well as repeat PB.
  
  
  METHODS
  A non-systematic review of the literature was performed from 2000 through 2013. Studies of highest evidence (randomized controlled trials, prospective non-randomized studies, and retrospective reports of high quality) comparing standard vs saturation schemes on initial and repeat PB were evaluated. Outcome measures were overall PCa detection rate, detection rate of insignificant PCa, and procedure-associated morbidity.
  
  
  RESULTS
  On initial PB, there is growing evidence that a saturation scheme is associated with a higher PCa detection rate compared to a standard one in men with lower PSA levels (<10 ng/ml), larger prostates (>40 cc), or lower PSA density values (<0.25 ng/ml/cc). However, these cut-offs are not uniform and differ among studies. Detection rates of insignificant PCa do not differ in a significant fashion between standard and saturation biopsies. On repeat PB, PCa detection rate is likewise higher with saturation protocols. Estimates of insignificant PCa vary widely due to differing definitions of insignificant disease. However, the rates of insignificant PCa appear to be comparable for the schemes in patients with only one prior negative biopsy, while saturation biopsy seems to detect more cases of insignificant PCa compared to standard biopsy in men with two or more prior negative biopsies. Very extensive sampling is associated with a high rate of acute urinary retention, whereas other severe adverse events, such as sepsis, appear not to occur more frequently with saturation schemes.
  
  
  CONCLUSIONS
  Current evidence suggests that saturation schemes are associated with a higher PCa detection rate compared to standard ones on initial PB in men with lower PSA levels or larger prostates, and on repeat PB. Since most data are derived from retrospective studies, other endpoints such as detection rate of insignificant disease - especially on repeat PB - show broad variations throughout the literature and must, thus, be interpreted with caution. Future prospective controlled trials should be conducted to compare extended templates with newer techniques, such as image-guided sampling, in order to optimize PCa diagnostic strategy.
authors.affiliation: Department of Urology, Regio Clinic Wedel, Wedel, Germany. Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Hendrik
authors.initials: H
authors.lastname: Isbarn
authors.affiliation: Department of Urology, Urological Research Institute, Vita-Salute University San Raffaele, Milan, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Briganti
authors.affiliation: Department of Radiology, Ghent University Hospital, Ghent, Belgium.
authors.forename: Pieter J L
authors.initials: PJ
authors.lastname: De Visschere
authors.affiliation: Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
authors.forename: Jurgen J
authors.initials: JJ
authors.lastname: Fütterer
authors.affiliation: Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Pirus
authors.initials: P
authors.lastname: Ghadjar
authors.affiliation: Urology Unit, Academic Medical Centre Hospital "Santa Maria della Misericordia", Udine, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Giannarini
authors.affiliation: Department of Radiation Oncology and Experimental Cancer Research, Ghent University Hospital, Ghent, Belgium.
authors.forename: Piet
authors.initials: P
authors.lastname: Ost
authors.affiliation: Department of Urology, Saint-Jean Languedoc Hospital, Toulouse, France. Department of Urology, CHU Saint-Louis, Assistance Publique, Hôpitaux de Paris, Université Pari, Paris, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Ploussard
authors.affiliation: Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, U.K. Department of Molecular Medicine & Surgery, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Prasanna
authors.initials: P
authors.lastname: Sooriakumaran
authors.affiliation: Centre of Urological Surgery, Dialysis and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania.
authors.forename: Christian I
authors.initials: CI
authors.lastname: Surcel
authors.affiliation: Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
authors.forename: Inge M
authors.initials: IM
authors.lastname: van Oort
authors.affiliation: Department of Urology, Rabin Medical Center - Beilinson, Petach-Tikva, Israel. Sackler Faculty of Medicine, University of Tel Aviv, Tel Aviv, Israel.
authors.forename: Ofer
authors.initials: O
authors.lastname: Yossepowitch
authors.affiliation: Department of Urology, University Medical Centre Utrecht, Utrecht, the Netherlands.
authors.forename: Roderick C N
authors.initials: RC
authors.lastname: van den Bergh
mesh_terms: D006801:Humans; D061705:Image-Guided Biopsy / Q000379:methods; D008297:Male; D011467:Prostate / Q000000981:diagnostic imaging* / Q000473:pathology*; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology*; D018084:Ultrasonography, Interventional