PARASAGITTAL BIOPSIES ADD MINIMAL INFORMATION IN REPEAT SATURATION PROSTATE BIOPSY AMIT R. PATEL, J. STEPHEN JONES, JOHN RABETS, GERARD DEOREO, AND CRAIG D. ZIPPE ABSTRACT Objectives. To compare the outcome and efficacy of lateral biopsies with parasagittal biopsies in detecting prostate cancer during repeated biopsies performed using the “saturation” technique, which includes 24 cores per biopsy. Prostate biopsy may miss cancer in up to 38% of men eventually found to harbor the disease. Lateral biopsies are more likely than parasagittal biopsies to detect adenocarcinoma according to the findings of several studies. Methods. A total of 100 patients, average age 62.1  7.9 years, underwent repeated transrectal ultra- sound-guided saturation biopsy. The study group included 31 patients with previous biopsy results demon- strating high-grade prostatic intraepithelial neoplasia, 7 with atypia, and 62 with benign prostatic tissue but persistently elevated prostate-specific antigen levels. Patients had undergone an average of 1.65 previous biopsies. The average prostate-specific antigen level was 9.4  6.8 ng/mL. Biopsies were obtained from five sectors on each side and examined histologically. Results. Cancer was detected in 25 (25%) of the 100 patients. Malignancy was identified in the lateral cores of all patients with positive biopsies. Parasagittal biopsy cores were positive in association with a lateral- based biopsy in 9 (36%) of the 25 malignancies, for an overall parasagittal biopsy core rate of 9% (9 of 100 patients). No cancers were detected in the parasagittal biopsy cores alone. Conclusions. Inclusion of parasagittal zone biopsy cores proved to have a low yield in detecting cancer on repeated biopsy. As all patients found to have cancer in the parasagittal biopsy cores also had cancer on the lateral biopsy cores, most time and effort can be spent obtaining lateral biopsy cores to increase the sensitivity on repeated saturation biopsy. UROLOGY 63: 87–89, 2004. © 2004 Elsevier Inc. R epeat prostate biopsy is a common procedure in men with increasing prostate-specific anti- gen (PSA) levels, abnormal digital rectal examina- tion findings, or previous abnormal nonmalignant prostate pathologic findings such as prostatic in- traepithelial neoplasia or atypia. Up to one third of men refuse to undergo repeated biopsy, regardless of the prior number of biopsies. 1 Fortunately, with the popularization of the periprostatic block to achieve local anesthesia, the pain and morbidity have reached acceptable levels. 2,3 Although debate continues about how to conduct the repeat biopsy, it is clear that location is an impor- tant factor in the detection of prostate cancer on re- peat biopsy. Stamey 4 found that performing sextant biopsies laterally instead of in the traditional parasag- ittal location increased biopsy accuracy. Gore et al. 5 recommended a biopsy strategy that included later- ally directed cores to increase the cancer detection yield. In addition, three-dimensional computer-sim- ulated biopsy studies have suggested that lateral pros- tate biopsies increase the cancer detection rate. 6 These recommendations contrast with saturation protocols that emphasize other areas of the prostate, specifically the one suggested by Eskew et al. 7 of an extended five-region biopsy protocol that empha- sized the inclusion of midline biopsies. We have found that most positive biopsies are located in the lateral cores and prospectively eval- uated the location of positive biopsies to determine the sectors that are important during repeated 24- core saturation prostate biopsy. MATERIAL AND METHODS From February 2002 to July 2003, a total of 100 patients underwent repeated transrectal ultrasound-guided saturation From the Glickman Urological Institute, Cleveland Clinic Foun- dation, Cleveland, Ohio Reprint requests: J. Stephen Jones, M.D., Glickman Urological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A-100, Cleveland, OH 44195 Submitted: May 30, 2003, accepted (with revisions): August 28, 2003 ADULT UROLOGY © 2004 ELSEVIER INC. 0090-4295/04/$30.00 ALL RIGHTS RESERVED doi:10.1016/j.urology.2003.08.040 87