Prostate Cancer Extended 21-Sample Needle Biopsy Protocol for Diagnosis of Prostate Cancer in 1000 Consecutive Patients Guillaume Guichard a , Ste ´phane Larre ´ a , Andrea Gallina a , Adi Lazar a , Hugo Faucon a , Ste ´phanie Chemama a , Yves Allory b , Jean-Jacques Patard b , Dimitri Vordos a , Andras Hoznek a , Rene ´ Yiou a , Laurent Salomon a , Claude Cle ´ment Abbou a , Alexandre de la Taille a, * a INSERM U841EQ07, Department of Urology APHP, Cre ´teil, France b Department of Urology, CHU Rennes, Rennes, France european urology 52 (2007) 430–435 available at www.sciencedirect.com journal homepage: www.europeanurology.com Article info Article history: Accepted February 28, 2007 Published online ahead of print on March 13, 2007 Keywords: Prostate biopsy Prostate cancer Diagnostic yield Abstract Objective: To prospectively evaluate the diagnostic yield of a 21-sample ultrasound-guided needle biopsy protocol as the initial diagnostic strategy for detection of prostate cancer. Materials and methods: Between December 2001 and October 2005, 1000 consecutive patients underwent 21-sample needle biopsies under local anesthesia, comprising sextant biopsies, 3 additional posterolateral biopsies in each peripheral zone, 3 biopsies in each transition zone (TZ), and 3 biopsies in the midline peripheral zone. Each prostate core was numbered and analyzed separately. The patients were divided into subgroups according to the result of digital rectal examination (DRE), serum prostate-specific antigen (PSA), and prostate volume. We evaluated the cancer detection rate overall and in each subgroup. We compared the results of our biopsy protocol to those from 6-, 12-, and 18-core biopsy protocols by analyzing only those cores from our protocol that would correspond to these biopsy schemes. Results: Cancer detection rates using 6 biopsy samples (sextant biopsies only), 12 samples (sextant plus lateral biopsies), 18 samples (sextant, lateral, and TZ biopsies), and 21 samples (sextant, lateral, TZ, plus midline biopsies) were 31.7%, 38.7%, 41.5%, and 42.5%, respectively. The 12-sample procedure improved the cancer detection rate by 22% compared with the 6-sample procedure ( p = 0.0001). The improvement in the diagnostic yield was most marked in patients with a prostate volume 55 ml (36.9%), in patients with normal DRE (26.6%), and in patients with PSA < 4 (37.5%). The addition of TZ biopsies to a 12-biopsy scheme increased the diagnostic yield by 7.2% overall ( p = 0.023). Only 10 of 425 (2.3%) patients were diagnosed on the sole basis of midline biopsies. Conclusions: Patients with suspected localized prostate cancer should be offered at least 12 biopsies in the peripheral zone and far lateral peripheral zone (statistically significant). TZ biopsies have to be considered, because these biopsies improve the diagnostic yield. For patients with abnormal DRE and/or PSA  20 ng/ml, the 6-biopsy scheme seems sufficient (statistically), but 6 far lateral peripheral zone biopsies as well as the TZ biopsies add little incremental value (not significant). Evidence does not support the use of routine midline peripheral zone needle biopsies in the initial biopsy to enhance the detection of prostate cancer. # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. INSERM U841EQ07, De ´ partement d’Urologie, CHU Henri Mondor, 54 bd du Gal de Lattre de Tassigny, 94000 Cre ´teil, France. Tel. +33 1 49 81 25 54; Fax: +33 1 49 81 25 68. E-mail address: adelataille@hotmail.com (A. de la Taille). 0302-2838/$ – see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2007.02.062