Office Based Transrectal Saturation Biopsy Improves Prostate Cancer Detection Compared to Extended Biopsy in the Repeat Biopsy Population Osama M. Zaytoun, Ayman S. Moussa, Tianming Gao, Khaled Fareed and J. Stephen Jones*,† From the Glickman Urological and Kidney Institute and Department of Quantitative Health Sciences (TG), Cleveland Clinic, Cleveland, Ohio Abbreviations and Acronyms ASAP = atypical small acinar proliferation DRE = digital rectal examination HGPIN = high grade prostatic intraepithelial neoplasia PBx = prostate biopsy PCa = prostate cancer PSA = prostate specific antigen TRUS = transrectal ultrasound Submitted for publication January 13, 2011. Study received institutional review board ap- proval. * Correspondence: Department of Regional Urology, Glickman Urological and Kidney Insti- tute, Cleveland Clinic, 9500 Euclid Ave., A100, Cleveland Ohio 44195 (telephone: 216-444-2470; FAX: 216-445-2267; e-mail: joness7@ccf.org). † Financial interest and/or other relationship with Pfizer, Cook, Abbott, Endocare and GTx. For another article on a related topic see page 1093. Purpose: Multiple studies have shown significant prostate cancer detection for repeat biopsy. However, the best approach regarding core number and location remains controversial. Transrectal saturation biopsy is believed to increase can- cer detection but to our knowledge no studies comparing it to 12 to 14-core extended biopsy have been published. We compared saturation and extended repeat biopsy protocols after initially negative biopsy. Materials and Methods: A total of 1,056 men underwent prostate biopsy after initially negative biopsy. The extended biopsy group included 393 men with 12 to 14-core repeat biopsy. The saturation biopsy group included 663 men with 20 to 24-core repeat biopsy. We analyzed demographics and prostate cancer between the 2 groups. We compared prostate cancer detection in patients with previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia as well as the risk of detecting clinically insignificant tumors. Results: Prostate cancer was detected in 315 of the 1,056 patients (29.8%). Satura- tion biopsy detected almost a third more cancers (32.7% vs 24.9%, p = 0.0075). In patients with a benign initial biopsy saturation biopsy achieved significantly greater prostate cancer detection (33.3% vs 25.6%, p = 0.027). For previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia there was a trend toward higher prostate cancer detection rate in the saturation group but it did not attain statistical significance (31.2% vs 23.3%, p = 0.13). Of 315 positive biopsies 119 (37.8%) revealed clinically insignificant cancer (40.1% vs 32.6%, p = 0.2). Conclusions: Compared to extended biopsy, office based saturation biopsy signifi- cantly increases cancer detection on repeat biopsy. The potential for increased detection of clinically insignificant cancer should be weighed against missing significant cases. Key Words: prostate, prostatic neoplasms, biopsy, physicians’ offices, reoperation AFTER its introduction by Hodge et al 1 sextant PBx remained the mainstay of PCa diagnosis for several years. However, several investigators re- ported a high probability that this limited parasagittal scheme would miss cancer. 2,3 Currently initial PBx should include at least 10 to 14 ex- tended cores, including the lateral and anterior prostate zones, based on superior cancer detection rates. 4,5 Even with the widespread applica- tion of extended PBx it is well recog- nized that many PCa cases are still missed at initial PBx due to sampling error and, thus, negative PBx does 850 www.jurology.com 0022-5347/11/1863-0850/0 Vol. 186, 850-854, September 2011 THE JOURNAL OF UROLOGY ® Printed in U.S.A. © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. DOI:10.1016/j.juro.2011.04.069