U J - Spring 2012.pdf 491Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L Is It Effective to Perform Two More Pros- tate Biopsies According to Prostate-Spe- cific Antigen Level and Prostate Volume in Detecting Prostate Cancer? Prospective Study of 10-Core and 12-Core Prostate Biopsy Byung Il Yoon, Tae Seung Shin, Hyuk Jin Cho, Sung-Hoo Hong, Ji Youl Lee, Tae-Kon Hwang , Sae Woong Kim Purpose: volume. Materials and Methods: - amination and transrectal ultrasonography, received transrectal ultrasound-guided prostate biopsies. The patients were prospectively randomized to undergo 10-core were assessed and compared according to the serum level of PSA and prostate volume. Results: P = both groups. Comparing the cancer detection rates according to the prostate vol- P Conclusion: The overall cancer detection rates showed no differences in both Keywords: Corresponding Author: Sae Woong Kim, MD Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea Seoul St Mary’s Hospital, 505 Banpo-dong, Seocho- gu, Seoul, 137-701, Korea Tel: +822 2258 6226 Fax: +822 599 7839 E-mail: ksw1227@catholic. ac.kr Received April 2011 Accepted December 2011 Department of Urology, The Catholic University of Korea, College of Medicine, Seoul, Korea Urological Oncology 492 | INTRODUCTION Ahave become generalized for the screen- patients receiving the prostate biopsy is increas- ing. Since Hodge and colleagues proposed tran- - tate biopsy, it has become the standard method for the diagnosis of the PCa. But sextant biopsies 30% in the PCa detection. in sextant biopsy, several studies have suggested the extended prostate biopsy to improve the can- cer detection rates compared to standard sextant prostate biopsy; however, this issue is still un- der debate. While some authors reported that ex- tended prostate biopsy did not only improve the PCa detection rates, but also increased morbidity rates due to increased biopsy samples. Recently, many urologists are more labile to per- form extended prostate biopsy rather than the conventional sextant biopsy. Most of the studies reported previously are on the comparison of sex- tant with extended biopsies. Our aim was to eval- uate the PCa detection rates of extended biopsy of - MATERIALS AND METHODS a central ethical committee (Catholic Medical Center, The Catholic University of Korea College and then by the respective local ethical commit- tees. for the prostate biopsy with elevated serum levels written informed consent was obtained from each participant. core biopsies; 351 patients received 10-core pros- biopsy cores were obtained from the lateral pe- the lateral peripheral zone biopsy cores were tak- biopsy, apex of the lateral peripheral zone biopsy cores was added to 10-core prostate biopsy. - acin starting pre-biopsy and continued twice daily for 5 days. Prior to the prostate biopsy, soap-saline enema was performed for the patients, and qui- nolones antibiotics were injected intravenously. continued for additional 7 days. The patient was discharged the day after the prostate biopsy after hematuria, acute prostatitis, rectal bleeding, vas- ovagal syncope, and acute urinary retention. Prostate volume was measured by the applica- × transverse length × vertical length × anteropos- We evaluated the PCa detection - Urological Oncology Figure. b) Position of 12-core biopsy. 493Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L Two More Prostate Biopsies for PCa Diagnosis | Yoon et al Furthermore, we evaluated the PCa detection - Data were analyzed using SPSS software (the Statistical Package for the Social Sciences, Ver- assess the differences between the groups, inde- pendent samples t test and Pearson Chi-Square test were used. P values less than .05 were con- RESULTS there were no differences between the two groups (P P - respectively (P - in Table 1. When the cancer detection rates of 10-core and - tate cancer detection rates showed no statistically P P When the cancer detection rates of 10-core and P Table 1. Clinical characteristics and cancer detection rate of the patients. Total 10-core prostate biopsy 12-core prostate biopsy P Number of patients 474 351 123 Age, y 65.9 ± 9.7 66.5 ± 9.5 64.4 ± 10.2 .053 Prostate-specific antigen, ng/mL 10.9 ± 15.3 10.5 ± 13.3 12.1 ± 20.1 .411 Prostate volume, mL 42.4 ± 20.7 42.6 ± 22.4 42.0 ± 14.9 .723 Cancer detection rate, n (%) 93 (26.4) Table 2. Prostate cancer detection rate according to the serum level of prostate-specific antigen and prostate volume. Total 10-core prostate biopsy 12-core prostate biopsy P Prostate-specific antigen, ng/mL 2.5 to 4.0 3/19 (15.7%) .540 4.1 to 10.0 66/293 (22.5 %) 16/74 (21.6%) 10.1 to 20.0 54/124 (43.5 %) 16/30 (53.3%) .152 Prostate volume, mL < 40 .331 ≥ 40 42/215 (19.5%) 25/152 (16.4%) 17/63 (26.9%) .049 494 | mL (P core biopsy scheme according to PSA levels and prostate biopsy-related complications. The most common complication was mild hematuria (30%; treatments. Other complications were acute pros- - - ble 3. DISCUSSION With the increased concern of PCa and the wide spread use of serum PSA test, performing prostate biopsy for the detection of the PCa is increasing. Due to the low sensitivity of PSA testing, age- independent markers of the presence, nature, and progression of the PCa are needed to facilitate timely diagnosis and treatment. Recently, metab- olomics or metabonomics have been proposed as a novel method of PCa detection. But these meth- ods are still under study and most of countries are using PSA as the screening of the PCa. The estimated cancer detection rate in Korean men 55 years or older is 3.36%. Among all can- cers, the incidence of PCa increased most in Ko- 6-core prostate biopsy, it has been the most widely used method for diagnosing PCa. Several studies reported that the PCa detection rates of - tions because of not considering the PV and loca- tion of tumor. Many studies attempted to improve the PCa de- tection rates by increasing the number of biopsy samples using 8-core, 10-core, biopsy. These extended prostate biopsies im- proved PCa detection rates and the complication rates were comparable to conventional 6-core biopsy. Presti and colleagues and Moon and associates reported that the 10-core biopsy detection rates up to 19%. Rochester and asso- ciates reported that PCa detection rates improved - pared with conventional 6-core biopsy group. In studies that compared the 6-core biopsy group with the extended biopsy group, Naughton and coworkers reported that the PCa detection rate in Bae and Chang reported - tients who were suspected to have T1c PCa. They Urological Oncology Table 3. Total 10-core prostate biopsy 12-core prostate biopsy P Hematuria 142 (30%) 102 (29.0%) 40 (32.5%) Acute prostatitisa 10 (2.0%) 7 (1.9%) 3 (2.4%) Rectal bleeding 5 (1.0%) 4 (1.1%) Vasovagal syncope 3 (0.6%) 1 (0.2%) 2 (1.6%) .732 Acute urinary retentionb 0 (0%) 0 (0%) 0 (0%) - a Fever > 37.5 ºC and white blood cells/high power field in urine analysis > 4 b Residual urine volume > 200 mL 495Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L improve the cancer detection rates in suspicious T1c PCa. Several recent studies have examined the cancer detection rates with saturation biopsy. Lane and rate for saturation biopsy was the same as that found with traditional prostate biopsy. Pepe and saturation technique. A retrospective comparison showed comparable detection rates of 39.8% and Our study was different from many other previous studies that compared the 6-core biopsy regimen with the extended biopsy protocols. Our aim was to evaluate the PCa detection rates in extended - opsies in PCa detection. Our results showed that the rate of PCa detection rates of the 10-core and - tively. Performing additional two more biopsies to the 10-core biopsy protocol did not improve PCa detection rate. Limitation of our study is that we excluded conventional 6-core biopsy and compared its detection rate only with extended prostate biopsy. considered to the standard cutoff value of pros- recommended performing prostate biopsy even - - tected in these patients. Catalona and colleagues might be overlooked. In patients with increased - We found that PCa detection rates improved with the increase of the PSA levels, but no statistical prostate biopsies according to the PSA levels. Prostate size plays an important role in the diag- nosis of PCa, because it correlates directly with the relative amount of tissue sampled per biopsy core. Prostate cancer detection rate is known to be related to the PV, varying from 39% in small glands to 10% in large prostates. But the impact of PV on the prostate biopsy in detecting PCa is still controversial. Several researchers have reported that PCa detection rates decrease with increasing the PV. Uzzo and colleagues consid- ered the PV of 50 mL as cutoff and Mariappan - cantly higher in the small PV. did not respond to medical treatment. In our re- sults, the PCa detection rate of the small PV (< biopsy. In small PV group, PCa detection rates - detection rates compared with 10-core biopsy - in addition to 10-core biopsy can help improve the PCa detection rate. In many centers in Korea, prostate biopsy is done on outpatient basis, but some centers pre- fer to practice biopsy with hospitalized patients. Two More Prostate Biopsies for PCa Diagnosis | Yoon et al 496 | The reason why we hospitalized the patients is to check and prevent severe complications af- ter the prostate biopsy. With the increase of the number of biopsy samples, the rates of compli- cations, such as hematuria, rectal bleeding, and infection, may be increased. But complications after the prostate biopsy are usually minor. In our results, mild hematuria was the most com- mon complication after the prostate biopsy, but special treatments were not required in most of the patients. The complication rate of hematuria, acute prostatitis, rectal bleeding, and vasovagal biopsies yielded similar complication rate with- more additional biopsies without worrying about an increase in complication rate with increased samplings. CONCLUSION - - improve the PCa detection rates. With regard to the cutoff of serum levels of PSA and the PV for the application of extended prostate biopsy, the more prospective studies with larger number of patients are needed in the future. ACKNOWLEDGEMENTS We are thankful to Seol Kim and Woong-Jin Bae from the Department of Urology in our institution for data processing of case materials. CONFLICT OF INTEREST None declared. Urological Oncology REFERENCES 1. Hodge KK, McNeal JE, Terris MK, Stamey TA. Random sys- tematic versus directed ultrasound guided transrectal core 4-5. 2. Naughton CK, Smith DS, Humphrey PA, Catalona WJ, Keetch DW. Clinical and pathologic tumor characteristics of prostate cancer as a function of the number of biopsy 3. Levine MA, Ittman M, Melamed J, Lepor H. Two consecu- tive sets of transrectal ultrasound guided sextant biopsies of the prostate for the detection of prostate cancer. J Urol. 4. Loch T, Eppelmann U, Lehmann J, Wullich B, Loch A, Stockle M. Transrectal ultrasound guided biopsy of the prostate: random sextant versus biopsies of sono-morphologically 5. MacMahon PJ, Kennedy AM, Murphy DT, Maher M, McNich- olas MM. Modified prostate volume algorithm improves transrectal US volume estimation in men presenting for 6. Song C, Ahn H, Lee MS, et al. Mass screening for pros- tate cancer in Korea: a population based study. J Urol. 7. Norberg M, Egevad L, Holmberg L, Sparen P, Norlen BJ, Busch C. The sextant protocol for ultrasound-guided core biopsies of the prostate underestimates the presence of Ravery V, Goldblatt L, Royer B, Blanc E, Toublanc M, Boccon- Gibod L. Extensive biopsy protocol improves the detection 9. Lee SB, Kim CS. Comparative analysis of sextant and ex- 10. Moon KH, Cheon SH, Kim CS. Systematic 10-site prostate biopsy is superior to sextant method for diagnosing carci- 11. Presti JC, Jr., O'Dowd GJ, Miller MC, Mattu R, Veltri RW. Extended peripheral zone biopsy schemes increase cancer detection rates and minimize variance in prostate specific antigen and age related cancer rates: results of a commu- 12. Bae KS, Chang SG. Comparative analysis between sextant biopsy and 12-samples needle biopsy for detection of 497Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L 13. Presti JC, Jr., Chang JJ, Bhargava V, Shinohara K. The optimal than 6 biopsies: results of a prospective clinical trial. J Urol. 14. Durkan GC, Sheikh N, Johnson P, Hildreth AJ, Greene DR. Improving prostate cancer detection with an extended- core transrectal ultrasonography-guided prostate biopsy 15. - spective randomised trial of extended core prostate biopsy 9. 16. Naughton CK, Miller DC, Mager DE, Ornstein DK, Catalona WJ. A prospective randomized trial comparing 6 versus 12 prostate biopsy cores: impact on cancer detection. J Urol. 17. Lane BR, Zippe CD, Abouassaly R, Schoenfield L, Magi-Gal- luzzi C, Jones JS. Saturation technique does not decrease cancer detection during followup after initial prostate Pepe P, Aragona F. Saturation prostate needle biopsy and prostate cancer detection at initial and repeat evaluation. 19. Catalona WJ, Smith DS, Ornstein DK. Prostate cancer detection in men with serum PSA concentrations of 2.6 to 4.0 ng/mL and benign prostate examination. Enhance- ment of specificity with free PSA measurements. JAMA. 20. Karakiewicz PI, Bazinet M, Aprikian AG, et al. Outcome of sextant biopsy according to gland volume. Urology. 21. Uzzo RG, Wei JT, Waldbaum RS, Perlmutter AP, Byrne JC, Vaughan ED, Jr. The influence of prostate size on cancer 22. Mariappan P, Chong WL, Sundram M, Mohamed SR. Increasing prostate biopsy cores based on volume vs the sextant biopsy: a prospective randomized controlled clini- cal study on cancer detection rates and morbidity. BJU Int. 23. of first and repeat transrectal ultrasound guided prostate needle biopsies: results of a prospective European prostate Two More Prostate Biopsies for PCa Diagnosis | Yoon et al